Cesarean hysterectomy for placenta accreta spectrum: Surgeon specialty-specific assessment

OBJECTIVE

To assess (i) clinical and pregnancy characteristics, (ii) patterns of surgical procedures, and (iii) surgical morbidity associated with cesarean hysterectomy for placenta accreta spectrum based on the specialty of the attending surgeon.

METHODS

The Premier Healthcare Database was queried retrospectively to study patients with placenta accreta spectrum who underwent cesarean delivery and concurrent hysterectomy from 2016 to 2020. Surgical morbidity was assessed with propensity score inverse probability of treatment weighting based on surgeon specialty for hysterectomy: general obstetrician-gynecologists, maternal-fetal medicine specialists, and gynecologic oncologists.

RESULTS

A total of 2240 cesarean hysterectomies were studies. The most common surgeon type was general obstetrician-gynecologist (n = 1534, 68.5%), followed by gynecologic oncologist (n = 532, 23.8%) and maternal-fetal medicine specialist (n = 174, 7.8%). Patients in the gynecologic oncologist group had the highest rate of placenta increta or percreta, followed by the maternal-fetal medicine specialist and general obstetrician-gynecologist groups (43.4%, 39.6%, and 30.6%, P < .001). In a propensity score-weighted model, measured surgical morbidity was similar across the three subspecialty groups, including hemorrhage / blood transfusion (59.4-63.7%), bladder injury (18.3-24.0%), ureteral injury (2.2-4.3%), shock (8.6-10.5%), and coagulopathy (3.3-7.4%) (all, P > .05). Among the cesarean hysterectomy performed by gynecologic oncologist, hemorrhage / transfusion rates remained substantial despite additional surgical procedures: tranexamic acid / ureteral stent (60.4%), tranexamic acid / endo-arterial procedure (76.2%), ureteral stent / endo-arterial procedure (51.6%), and all three procedures (55.4%). Tranexamic acid administration with ureteral stent placement was associated with decreased bladder injury (12.8% vs 23.8-32.2%, P < .001).

CONCLUSION

These data suggest that patient characteristics and surgical procedures related to cesarean hysterectomy for placenta accreta spectrum differ based on surgeon specialty. Gynecologic oncologists appear to manage more severe forms of placenta accreta spectrum. Regardless of surgeon's specialty, surgical morbidity of cesarean hysterectomy for placenta accreta spectrum is significant.

Trends in Attempted Vaginal Delivery among Pregnancies Complicated by Gastroschisis, 2014 to 2020

OBJECTIVE

 Gastroschisis is a full-thickness congenital defect of the abdominal wall through which intestines and other organs may herniate. In a prior analysis, attempted vaginal delivery with fetal gastroschisis appeared to increase through 2013, although cesarean delivery remained common. The objective of this analysis was to update current trends in attempted vaginal birth among pregnancies complicated by gastroschisis.

STUDY DESIGN

 We performed an updated cross-sectional analysis of live births from 2014 and 2020 using data from the U.S. National Vital Statistics System and evaluated trends in attempted vaginal deliveries among births with gastroschisis. Trends were evaluated using joinpoint regression. We constructed logistic regression models to evaluate the association between demographic and clinical variables and attempted vaginal delivery in the setting of gastroschisis.

RESULTS

 Among 5,355 deliveries with gastroschisis meeting inclusion criteria, attempted vaginal delivery increased significantly from 68.9% to 75.1%, an average annual percent change of 1.7% (95% confidence interval [CI], 0.8-2.5). Among gastroschisis-complicated pregnancies, patients 35 to 39 years old (adjusted odds ratio [aOR], 0.53; 95% CI, 0.37-0.79) and Hispanic race/ethnicity (aOR, 0.69; 95% CI, 0.58-0.62) were at lower likelihood of attempted vaginal delivery in adjusted analyses.

CONCLUSION

 These findings suggest that vaginal delivery continues to increase in the setting of gastroschisis. Further reduction of surgical delivery for this fetal defect may be possible.

KEY POINTS

· Vaginal deliveries increased among gastroschisis pregnancies.. · Hispanic patients were less likely to attempt vaginal delivery.. · Some gastroschisis pregnancies still deliver surgically..

Trends in and outcomes of delivery hospitalizations with lupus and antiphospholipid syndrome

OBJECTIVE

To assess trends and outcomes associated with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) during US delivery hospitalizations.

STUDY DESIGN

The National Inpatient Sample from 2000 to 2019 was used for this repeated cross-sectional analysis. We identified delivery hospitalizations with and without SLE. Temporal trends in SLE during delivery hospitalizations were determined using joinpoint regression. Adjusted logistic regression models accounting for demographic, clinical, and hospital factors were used to determine adjusted odds ratios (aORs) for adverse outcomes based on the presence or absence of SLE.

RESULTS

Of an estimated 76 698 775 delivery hospitalizations identified in the NIS, 79386 (0.10%) had an associated diagnosis of SLE. Over the study period, SLE increased from 6.7 to 14.6 cases per 10 000 delivery hospitalizations (average annual percent change 4.5%, 95% CI 4.0-5.1). Deliveries with SLE had greater odds of non-transfusion severe morbidity (aOR 2.21, 95% CI 2.00, 2.44) and underwent a larger absolute increase in morbidity risk over the study period. SLE was associated with a range of other adverse outcomes including preterm delivery, eclampsia, cesarean delivery, and blood transfusion.

CONCLUSION

The proportion of deliveries to women with SLE has increased over time in the US, and SLE and APS are associated with a broad range of adverse outcomes.

Risk Factors, Trends, and Outcomes Associated With Postpartum Sepsis Readmissions

OBJECTIVE

To evaluate the prevalence, timing, clinical risk factors, and adverse outcomes associated with postpartum readmissions for maternal sepsis.

METHODS

We conducted a retrospective cohort study of delivery hospitalizations and 60-day postpartum readmissions for females aged 15-54 years with and without sepsis using the 2016-2020 Nationwide Readmissions Database. Temporal trends in sepsis diagnoses during delivery hospitalizations and 60-day postpartum readmissions were analyzed with the National Cancer Institute's Joinpoint Regression Program to estimate the average annual percent change with 95% CIs. Logistic regression models were fit to determine whether delivery hospitalization characteristics were associated with postpartum sepsis readmissions, and unadjusted and adjusted odds ratios with 95% CIs were reported. Adverse outcomes associated with sepsis during delivery hospitalization and readmission were described, including death, severe morbidity, a critical care composite, and renal failure.

RESULTS

Overall, 15,268,190 delivery hospitalizations and 256,216 associated 60-day readmissions were included after population weighting, of which 16,399 (1.1/1,000 delivery hospitalizations) had an associated diagnosis of sepsis at delivery, and 20,130 (1.3/1,000 delivery hospitalizations) had an associated diagnosis of sepsis with postpartum readmission. A sepsis diagnosis was present in 7.9% of all postpartum readmissions. Characteristics associated with postpartum sepsis readmission included younger age at delivery, Medicaid insurance, lowest median ZIP code income quartile, and chronic medical conditions such as obesity, pregestational diabetes, and chronic hypertension. Postpartum sepsis readmissions were associated with infection during the delivery hospitalization, including intra-amniotic infection or endometritis, wound infection, and delivery sepsis. Sepsis diagnoses were associated with 24.4% of maternal deaths at delivery and 38.4% postpartum, 2.2% cases of nontransfusion severe morbidity excluding sepsis at delivery and 13.6% postpartum, 15.6% of critical care composite diagnoses at delivery and 30.1% postpartum, and 11.1% of acute renal failure diagnoses at delivery and 36.4% postpartum.

CONCLUSION

Sepsis accounts for a significant proportion of postpartum readmissions and is a major contributor to adverse outcomes during delivery hospitalizations and postpartum readmissions.

Infection and Sepsis Trends during United States' Delivery Hospitalizations from 2000 to 2020

OBJECTIVE

 This study aimed to evaluate trends, risk factors, and outcomes associated with infections and sepsis during delivery hospitalizations in the United States.

STUDY DESIGN

 The 2000-2020 National Inpatient Sample was used for this repeated cross-sectional analysis. Delivery hospitalizations of patients aged 15 to 54 with and without infection and sepsis were identified. Common infection diagnoses during delivery hospitalizations analyzed included (i) pyelonephritis, (ii) pneumonia/influenza, (iii) endometritis, (iv) cholecystitis, (v) chorioamnionitis, and (vi) wound infection. Temporal trends in sepsis and infection during delivery hospitalizations were analyzed. The associations between sepsis and infection and common chronic health conditions including asthma, chronic hypertension, pregestational diabetes, and obesity were analyzed. The associations between clinical, demographic, and hospital characteristics, and infection and sepsis were determined with unadjusted and adjusted logistic regression models with unadjusted odds ratio (OR) and adjusted odds ratios with 95% confidence intervals as measures of association.

RESULTS

 An estimated 80,158,622 delivery hospitalizations were identified and included in the analysis, of which 2,766,947 (3.5%) had an infection diagnosis and 32,614 had a sepsis diagnosis (4.1 per 10,000). The most common infection diagnosis was chorioamnionitis (2.7% of deliveries) followed by endometritis (0.4%), and wound infections (0.3%). Infection and sepsis were more common in the setting of chronic health conditions. Evaluating trends in individual infection diagnoses, endometritis and wound infection decreased over the study period both for patients with and without chronic conditions, while risk for pyelonephritis and pneumonia/influenza increased. Sepsis increased over the study period for deliveries with and without chronic condition diagnoses. Risks for adverse outcomes including mortality, severe maternal morbidity, the critical care composite, and acute renal failure were all significantly increased in the presence of sepsis and infection.

CONCLUSION

 Endometritis and wound infections decreased over the study period while risk for sepsis increased. Infection and sepsis were associated with chronic health conditions and accounted for a significant proportion of adverse obstetric outcomes including severe maternal morbidity.

KEY POINTS

· Sepsis increased over the study period for deliveries with and without chronic condition diagnoses.. · Endometritis and wound infection decreased over the study period.. · Infection and sepsis accounted for a significant proportion of adverse obstetric outcomes..

Adverse delivery hospitalisation outcomes in 2020 during the COVID-19 pandemic

OBJECTIVE

To evaluate risk for adverse obstetric outcomes associated with the coronavirus disease 2019 (COVID-19) pandemic period and with COVID-19 diagnoses.

DESIGN

Serial cross-sectional study.

SETTING

A national sample of US delivery hospitalisations before (1/2016 to 2/2020) and during the first 10 months of (3/2020 to 12/2020) the COVID-19 pandemic.

POPULATION

All 2016-2020 US delivery hospitalisations in the National Inpatient Sample.

METHODS

Delivery hospitalisations were identified and stratified into pre-pandemic and pandemic periods and the likelihood of adverse obstetric outcomes was compared using logistic regression models with adjusted odds ratios (aOR) with 95% confidence intervals (CI) as measures of association. Risk for adverse outcomes was also analysed specifically for 2020 deliveries with a COVID-19 diagnosis.

MAIN OUTCOME MEASURE

Adverse maternal outcomes including respiratory complications and cardiac morbidity.

RESULTS

Of an estimated 18.2 million deliveries, 2.9 million occurred during the pandemic. The proportion of delivery hospitalisations with a COVID-19 diagnosis increased from 0.1% in March 2020 to 3.1% in December. Comparing the pandemic period to the pre-pandemic period, there were higher adjusted odds of transfusion (aOR 1.12, 95% CI 1.05-1.19), a respiratory complication composite (aOR 1.37, 95% CI 1.29-1.46), cardiac severe maternal morbidity (aOR 1.30, 95% 1.20-1.39), postpartum haemorrhage (aOR 1.19, 95% CI 1.15-1.24), placental abruption/antepartum haemorrhage (OR 1.04, 95% CI 1.00-1.08), and hypertensive disorders of pregnancy (OR 1.23, 95% CI 1.21-1.26). These associations were similar to unadjusted analysis. Risk for these outcomes during the pandemic period was significantly higher in the presence of a COVID-19 diagnosis.

CONCLUSIONS

In a national estimate of delivery hospitalisations, the odds of cardiac and respiratory outcomes were higher in 2020 compared with 2016-2019. COVID-19 diagnoses were specifically associated with a range of serious complications.

State-Level Indicators of Structural Racism and Severe Adverse Maternal Outcomes During Childbirth

OBJECTIVES

Structural racism (SR) is viewed as a root cause of racial and ethnic disparities in maternal health outcomes. However, evidence linking SR to increased odds of severe adverse maternal outcomes (SAMO) is scant. This study assessed the association between state-level indicators of SR and SAMO during childbirth.

METHODS

Data for non-Hispanic Black and non-Hispanic white women came from the US Natality file, 2017-2018. The exposures were state-level Black-to-white inequity ratios for lower education level, unemployment, and prison incarceration. The outcome was patient-level SAMO, including eclampsia, blood transfusion, hysterectomy, or intensive care unit admission. Adjusted odds ratios (aORs) of SAMO associated with each ratio were estimated using multilevel models adjusting for patient, hospital, and state characteristics.

RESULTS

A total of 4,804,488 birth certificates were analyzed, with 22.5% for Black women. SAMO incidence was 106.4 per 10,000 (95% CI 104.5, 108.4) for Black women, and 72.7 per 10,000 (95% CI 71.8, 73.6) for white women. Odds of SAMO increased 35% per 1-unit increase in the unemployment ratio for Black women (aOR 1.35; 95% CI 1.04, 1.73), and 16% for white women (aOR 1.16; 95% CI 1.01, 1.33). Odds of SAMO increased 6% per 1-unit increase in the incarceration ratio for Black women (aOR 1.06; 95% CI 1.03, 1.10), and 4% for white women (aOR 1.04; 95% CI 1.02, 1.06). No significant association was observed between SAMO and the lower education level ratio.

CONCLUSIONS FOR PRACTICE

State-level Black-to-white inequity ratios for unemployment and incarceration are associated with significantly increased odds of SAMO.

Mode of Delivery and Obstetric Complications in the Setting of Prior Uterine Surgery

OBJECTIVE

 This study aimed to evaluate cesarean rates and risk for obstetric complications among deliveries with a history of prior uterine surgery.

STUDY DESIGN

 This serial cross-sectional study analyzed deliveries with and without prior uterine surgery in the 2016-2019 Nationwide Inpatient Sample. Unadjusted and adjusted logistic regression models were performed to assess risk of nontransfusion severe maternal morbidity (SMM) and other obstetric complications based on the presence or absence of prior uterine surgery with unadjusted and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) as measures of association. Adjusted models accounted for demographic, hospital, and delivery factors. Demographics and clinical factors among deliveries with and without a prior history of uterine surgery diagnosis were compared with the chi-square test with p < 0.05 considered statistically significant.

RESULTS

 Of 14.7 million delivery hospitalization identified, 6,910 (4.7 per 10,000) had a history of uterine surgery and 111,710 (0.76%) experienced SMM. Women with prior uterine surgery were more likely to be older, to be of unknown race or ethnicity, and to have private insurance (p < 0.01 for all). Eighty-five percent of deliveries with prior uterine surgery were performed by cesarean compared with 32% of deliveries without prior uterine surgery (p < 0.01). In adjusted analysis, compared with patients without prior uterine surgery, patients with prior uterine surgery were not at increased risk for SMM (aOR 1.23, 95% CI 0.73-2.07). Evaluating obstetric complications, patients with prior uterine surgery had a decreased risk of postpartum hemorrhage (aOR 0.64, 95% CI 0.43-0.96) and an increased risk of peripartum hysterectomy (aOR 4.12, 95% CI 1.75-9.67), and no difference in other obstetric complications assessed.

CONCLUSION

 These findings suggest that current clinical practice results in similar delivery risks among patients with compared with without prior uterine surgery.

KEY POINTS

· Risk for most adverse outcomes is similar among patients with prior uterine surgery.. · Risk for peripartum hysterectomy was higher with prior uterine surgery.. · Risk for SMM was not higher with prior uterine surgery..

Peripartum cardiomyopathy delivery hospitalization and postpartum readmission trends, risk factors, and outcomes

OBJECTIVE

To evaluate risk for peripartum cardiomyopathy during delivery and postpartum hospitalizations, and analyze associated trends, risk factors, and clinical outcomes.

METHODS

The 2010-2020 Nationwide Readmissions Database was used for this retrospective cohort study. Delivery hospitalizations along with postpartum readmissions occurring within five months of delivery discharge were analyzed. Risk factors associated with peripartum cardiomyopathy were analyzed with unadjusted and adjusted logistic regression models with odds ratios as measures of effect. Risk for severe adverse outcomes associated with peripartum cardiomyopathy was analyzed. Trends were analyzed with joinpoint regression.

RESULTS

Of 39,790,772 delivery hospitalizations identified, 9,210 were complicated by a diagnosis of peripartum cardiomyopathy (2.3 per 10,000). Risk for a 5-month readmission with a peripartum cardiomyopathy diagnosis was 4.8 per 10,000. Factors associated with peripartum cardiomyopathy during deliveries included preeclampsia with severe features (OR 18.9, 95 % CI 17.2, 20.7), preeclampsia without severe features (OR 6.9, 95 % CI 6.1, 7.8), multiple gestation (OR 4.7, 95 % CI 4.1, 5.3), chronic hypertension (OR 10.1, 95 % CI 8.9, 11.3), and older maternal age. Associations were attenuated but retained significance in adjusted models. Similar estimates were found when evaluating associations with postpartum readmissions. Peripartum cardiomyopathy readmissions were associated with 10 % of overall postpartum deaths, 21 % of cardiac arrest/ventricular fibrillation diagnoses, 18 % of extracorporeal membrane oxygenation cases, and 40 % of cardiogenic shock. In joinpoint analysis, peripartum cardiomyopathy increased significantly during delivery hospitalizations (average annual percent change [AAPC] 2.2 %, 95 % CI 1.0 %, 3.4 %) but not postpartum readmissions (AAPC 0.0 %, 95 % CI -1.6 %, 1.6 %).

CONCLUSION

Risk for peripartum cardiomyopathy increased during delivery hospitalizations over the study period. Obstetric conditions such as preeclampsia and chronic medical conditions that are increasing in prevalence in the obstetric population were associated with the highest odds of peripartum cardiomyopathy.

Continuation of psychiatric medications during pregnancy

Background: While medications for anxiety and depression are commonly used in the United States, it is unclear to what degree they are continued during pregnancy.Methods: We used a large administrative database to determine whether psychiatric medications are continued during pregnancy and predictors of continued medication treatment.Results: Of 2,672,656 women included in our analysis, 86,454 (3.1%) filled a pre-pregnancy prescription for an anxiolytic or antidepressant medication within 3 months of estimated conception. Of women who filled a pre-pregnancy prescription, 49.4%, 26.1%, and 20.1% filled subsequent prescriptions in the 1st, 2nd, and 3rd trimesters. Discontinuation rates ranged by pharmaceutical agent, from 16% for fluoxetine to 71% for alprazolam. White women and women over 25 were more likely to continue anxiolytic and antidepressant treatment during pregnancy.Conclusion: Because untreated and under-treated mental health conditions are linked to adverse maternal outcomes, high discontinuation rates may have important implications for maternal health.

Outcomes associated with peripartum hysterectomy in the setting of placenta accreta spectrum disorder

BACKGROUND

Although peripartum hysterectomy for placenta accreta spectrum disorder is known to be associated with complications at the time of delivery, there are limited data on postpartum outcomes and readmission risk in this population.

OBJECTIVE

This study aimed to analyze risks for adverse outcomes and postpartum readmissions in the setting of peripartum hysterectomy for placenta accreta spectrum disorder by severity of placenta accreta spectrum disorder subcategory.

STUDY DESIGN

Using the 2016-2020 Nationwide Readmissions Database, this retrospective cohort study identified peripartum hysterectomies with a diagnosis of placenta accreta spectrum disorder. The primary exposure was placenta accreta spectrum disorder, subcategorized as placenta accreta vs increta/percreta. The primary outcome was readmission rate and delivery complications. Complications evaluated included the following: (1) nontransfusion severe maternal morbidity (ntSMM), (2) venous thromboembolism, (3) reoperation, (4) intraoperative complications, (5) hemorrhage, (6) sepsis, and (7) surgical site complications. We additionally evaluated delivery hospitalization and readmission mean length of stay, and hospital costs. Unadjusted and adjusted logistic regression models were fit for outcomes adjusting for clinical, demographic, and hospital factors. The association measures were expressed as unadjusted and adjusted odds ratios with 95% confidence intervals.

RESULTS

Between 2016 and 2020, 7864 hysterectomies during a delivery hospitalization with a diagnosis of placenta accreta spectrum disorder were identified (66.5% with placenta accreta and 33.5% with placenta increta/percreta diagnoses). The overall 60-day all-cause readmission rate was 7.3%. Most readmissions (57.2%) occurred within 10 days of hospital discharge. Compared with peripartum hysterectomy with a diagnosis of placenta accreta, hysterectomies with placenta increta/percreta diagnoses carried significantly increased risk of 60-day readmission (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.71), inpatient mortality (odds ratio, 13.23; 95% confidence interval, 3.35-52.30), nontransfusion severe maternal morbidity (adjusted odds ratio, 1.43; 95% confidence interval, 1.20-1.71), intraoperative complications (adjusted odds ratio, 2.31; 95% confidence interval, 1.93-2.77), and surgical site complications (adjusted odds ratio, 1.55; 95% confidence interval, 1.23-1.95). The median length of stay during delivery hospitalization was longer for placenta increta/percreta (5.8 days; 95% confidence interval, 5.4-6.1) than for placenta accreta (4.2 days; 95% confidence interval, 4.1-4.3; P<.05). In addition, delivery hospitalization costs were higher in cases of placenta increta/percreta (median, $30,686; 95% confidence interval, $28,922-$32,449) than placenta accreta (median, $21,321; 95% confidence interval, $20,480-$22,163).

CONCLUSION

Complication and readmission risks after peripartum hysterectomy with placenta accreta spectrum disorder are high. Compared with patients with placenta accreta, patients with placenta increta/percreta had increased risk for delivery and postoperative complications and postpartum readmission, and increased costs and length of stay.

Delivery Outcomes and Postpartum Readmissions Associated with Ehlers-Danlos Syndrome

OBJECTIVE

 Given that updated estimates of Ehlers-Danlos syndrome and risks for obstetric complications including postpartum readmission may be of public health significance, we sought to analyze associated obstetric trends and outcomes in a nationally representative population.

STUDY DESIGN

 The 2016 to 2020 Nationwide Readmissions Database was used for this retrospective cohort study. Delivery hospitalizations to women aged 15 to 54 with and without Ehlers-Danlos syndrome were identified. Temporal trends in Ehlers-Danlos syndrome diagnoses during delivery hospitalizations were analyzed using joinpoint regression to estimate the average annual percent change with 95% confidence intervals (CIs). To determine whether adverse obstetric outcomes during the delivery were associated with Ehlers-Danlos syndrome, unadjusted and adjusted logistic regression models were fit with unadjusted (odds ratio [OR]) and adjusted ORs with 95% CIs as measures of association. In addition to analyzing adverse delivery outcomes, risk for 60-day postpartum readmission was analyzed.

RESULTS

 An estimated 18,214,542 delivery hospitalizations were included of which 7,378 (4.1 per 10,000) had an associated diagnosis of Ehlers-Danlos syndrome. Ehlers-Danlos syndrome diagnosis increased from 2.7 to 5.2 per 10,000 delivery hospitalization from 2016 to 2020 (average annual percent change increase of 16.1%, 95% CI: 9.4%, 23.1%). Ehlers-Danlos syndrome was associated with increased odds of nontransfusion severe maternal morbidity (OR: 1.84, 95% CI: 1.38, 2.45), cervical insufficiency (OR: 2.14, 95% CI: 1.46, 3.13), postpartum hemorrhage (OR: 1.41, 95% CI: 1.17, 1.68), cesarean delivery (OR: 1.26, 95% CI: 1.17, 1.36), and preterm delivery (OR: 1.35, 95% CI: 1.16, 1.56). Estimates for transfusion, placental abruption, and placenta previa did not differ significantly. Risk for 60-day postpartum readmission was 3.0% among deliveries with Ehlers-Danlos (OR: 1.76, 95% CI: 1.37, 2.25).

CONCLUSION

 Ehlers-Danlos syndrome diagnoses approximately doubled over the 5-year study period and was associated with a range of adverse obstetric outcomes and complications during delivery hospitalizations as well as risk for postpartum readmission.

KEY POINTS

· Ehlers-Danlos syndrome diagnoses approximately doubled over the 5-year study period.. · Ehlers-Danlos was associated with a range of adverse obstetric outcomes.. · Ehlers-Danlos was associated with increased readmission risk..

Postpartum readmission for hypertension and pre-eclampsia: development and validation of a predictive model

OBJECTIVE

To develop a model for predicting postpartum readmission for hypertension and pre-eclampsia at delivery discharge and assess external validation or model transportability across clinical sites.

DESIGN

Prediction model using data available in the electronic health record from two clinical sites.

SETTING

Two tertiary care health systems from the Southern (2014-2015) and Northeastern USA (2017-2019).

POPULATION

A total of 28 201 postpartum individuals: 10 100 in the South and 18 101 in the Northeast.

METHODS

An internal-external cross validation (IECV) approach was used to assess external validation or model transportability across the two sites. In IECV, data from each health system were first used to develop and internally validate a prediction model; each model was then externally validated using the other health system. Models were fit using penalised logistic regression, and accuracy was estimated using discrimination (concordance index), calibration curves and decision curves. Internal validation was performed using bootstrapping with bias-corrected performance measures. Decision curve analysis was used to display potential cut points where the model provided net benefit for clinical decision-making.

MAIN OUTCOME MEASURES

The outcome was postpartum readmission for either hypertension or pre-eclampsia <6 weeks after delivery.

RESULTS

The postpartum readmission rate for hypertension and pre-eclampsia overall was 0.9% (0.3% and 1.2% by site, respectively). The final model included six variables: age, parity, maximum postpartum diastolic blood pressure, birthweight, pre-eclampsia before discharge and delivery mode (and interaction between pre-eclampsia × delivery mode). Discrimination was adequate at both health systems on internal validation (c-statistic South: 0.88; 95% confidence interval [CI] 0.87-0.89; Northeast: 0.74; 95% CI 0.74-0.74). In IECV, discrimination was inconsistent across sites, with improved discrimination for the Northeastern model on the Southern cohort (c-statistic 0.61 and 0.86, respectively), but calibration was not adequate. Next, model updating was performed using the combined dataset to develop a new model. This final model had adequate discrimination (c-statistic: 0.80, 95% CI 0.80-0.80), moderate calibration (intercept -0.153, slope 0.960, Emax 0.042) and provided superior net benefit at clinical decision-making thresholds between 1% and 7% for interventions preventing readmission. An online calculator is provided here.

CONCLUSIONS

Postpartum readmission for hypertension and pre-eclampsia may be accurately predicted but further model validation is needed. Model updating using data from multiple sites will be needed before use across clinical settings.

The Predictive Value of Vital Signs for Morbidity in Pregnancy: Evaluating and Optimizing Maternal Early Warning Systems

OBJECTIVE

Vital sign scoring systems that alert providers of clinical deterioration prior to critical illness have been proposed as a means of reducing maternal risk. This study examined the predictive ability of established maternal early warning systems (MEWS)-as well as their component vital sign thresholds-for different types of maternal morbidity, to discern an optimal early warning system.

STUDY DESIGN

This retrospective cohort study analyzed all patients admitted to the obstetric services of a four-hospital urban academic system in 2018. Three sets of published MEWS criteria were evaluated. Maternal morbidity was defined as a composite of hemorrhage, infection, acute cardiac disease, and acute respiratory disease ascertained from the electronic medical record data warehouse and administrative data. The test characteristics of each MEWS, as well as for heart rate, blood pressure, and oxygen saturation were compared.

RESULTS

Of 14,597 obstetric admissions, 2,451 patients experienced the composite morbidity outcome (16.8%) including 980 cases of hemorrhage (6.7%), 1,337 of infection (9.2%), 362 of acute cardiac disease (2.5%), and 275 of acute respiratory disease (1.9%) (some patients had multiple types of morbidity). The sensitivities (15.3-64.8%), specificities (56.8-96.1%), and positive predictive values (22.3-44.5%) of the three MEWS criteria ranged widely for overall morbidity, as well as for each morbidity subcategory. Of patients with any morbidity, 28% met criteria for the most liberal vital sign combination, while only 2% met criteria for the most restrictive parameters, compared with 14 and 1% of patients without morbidity, respectively. Sensitivity for all combinations was low (maximum 28.2%), while specificity for all combinations was high, ranging from 86.1 to 99.3%.

CONCLUSION

Though all MEWS criteria demonstrated poor sensitivity for maternal morbidity, permutations of the most abnormal vital signs have high specificity, suggesting that MEWS may be better implemented as a trigger tool for morbidity reduction strategies in the highest risk patients, rather than a general screen.

KEY POINTS

· MEWS have poor sensitivity for maternal morbidity.. · MEWS can be optimized for high specificity using modified criteria.. · MEWS could be better used as a trigger tool..

Medicaid expansion and risk of eclampsia

BACKGROUND

Eclampsia is an indicator of severe maternal morbidity and can be prevented through increased prenatal care access and early prenatal care utilization. The 2014 Medicaid expansion under the Patient Protection and Affordable Care Act allowed states to expand Medicaid coverage to nonelderly adults with incomes up to 138% of the federal poverty level. Its implementation has led to a significant increase in prenatal care access and utilization.

OBJECTIVE

This study aimed to assess the association of Medicaid expansion under the Affordable Care Act with eclampsia incidence.

STUDY DESIGN

This natural experiment study was based on US birth certificate data from January 2010 to December 2018 in 16 states that expanded Medicaid in January 2014 and in 13 states that did not expand Medicaid during the study period. The outcome was eclampsia incidence, the intervention was the implementation of the Medicaid expansion, and the exposure was state expansion status. Using the interrupted time series method, we compared temporal trends in the incidence of eclampsia before and after the intervention in expansion vs non-expansion states with adjustments for patient and hospital county characteristics.

RESULTS

Of the 21,570,021 birth certificates analyzed, 11,433,862 (53.0%) were in expansion states and 12,035,159 (55.8%) were in the postintervention period. The diagnosis of eclampsia was recorded in 42,677 birth certificates or 19.8 per 10,000 (95% confidence interval, 19.6-20.0). The incidence of eclampsia was higher for Black people (29.1 per 10,000) than for White (20.7 per 10,000), Hispanic (15.3 per 10,000), and birthing people of other race and ethnicity (15.4 per 10,000). In the expansion states, the incidence of eclampsia increased during the preintervention period and decreased during the postintervention period; in the nonexpansion states, a reverse pattern was observed. A statistically significant difference was observed between expansion and nonexpansion states in temporal trends between the pre- and postintervention periods, with an overall 1.6% decrease (95% confidence interval, 1.3-1.9) in the incidence of eclampsia in expansion states compared with nonexpansion states. The results were consistent in subgroup analyses according to maternal race and ethnicity, education level (less than high school or high school and higher), parity (nulliparous or parous), delivery mode (vaginal or cesarean delivery), and poverty in the residence county (high or low).

CONCLUSION

Implementation of the Affordable Care Act Medicaid expansion was associated with a small statistically significant reduction in the incidence of eclampsia. Its clinical significance and cost-effectiveness remain to be determined.

Deliveries Among Patients With Maternal Hepatitis C Virus Infection in the United States, 2000-2019

OBJECTIVE

To assess clinical characteristics, trends, and outcomes associated with the diagnosis of hepatitis C virus (HCV) infection during pregnancy.

METHODS

This cross-sectional study analyzed delivery hospitalizations using the National Inpatient Sample. Temporal trends in both diagnosis of HCV infection and clinical characteristics associated with HCV infection were analyzed using joinpoint regression to estimate the average annual percent change (AAPC) with 95% CIs. Survey-adjusted logistic regression models were fit to assess the association among HCV infection and preterm delivery, cesarean delivery, and severe maternal morbidity (SMM), adjusting for clinical, medical, and hospital factors with adjusted odds ratios (aORs) as the measure of association.

RESULTS

An estimated 76.7 million delivery hospitalizations were included, in which 182,904 (0.24%) delivering individuals had a diagnosis of HCV infection. The prevalence of HCV infection diagnosed in pregnancy increased nearly 10-fold over the study period, from 0.05% in 2000 to 0.49% in 2019, representing an AAPC of 12.5% (95% CI 10.4-14.8%). The prevalence of clinical characteristics associated with HCV infection also increased over the study period, including opioid use disorder (from 10 cases/10,000 birth hospitalizations to 71 cases/10,000 birth hospitalizations), nonopioid substance use disorder (from 71 cases/10,000 birth hospitalizations to 217 cases/10,000 birth hospitalizations), mental health conditions (from 219 cases/10,000 birth hospitalizations to 1,117 cases/10,000), and tobacco use (from 61 cases/10,000 birth hospitalizations to 842 cases/10,000). The rate of deliveries among patients with two or more clinical characteristics associated with HCV infection increased from 26 cases per 10,000 birth hospitalizations to 377 cases per 10,000 delivery hospitalizations (AAPC 13.4%, 95% CI 12.1-14.8%). In adjusted analyses, HCV infection was associated with increased risk for SMM (aOR 1.78, 95% CI 1.61-1.96), preterm birth (aOR 1.88, 95% CI 1.8-1.95), and cesarean delivery (aOR 1.27, 95% CI 1.23-1.31).

CONCLUSION

Diagnosis of HCV infection is increasingly common in the obstetric population, which may reflect an increase in screening or a true increase in prevalence. The increase in HCV infection diagnoses occurred in the setting of many baseline clinical characteristics that are associated with HCV infection becoming more common.

Delivery trends and obstetric outcomes in patients with Fontan circulation

BACKGROUND

With improved therapies, an increasing number of patients with Fontan circulation reach reproductive age. Pregnant patients with Fontan circulation are at high risk for obstetric complications. Most data for Fontan pregnancies and associated complications stem from single center studies, with limited national epidemiologic data available.

OBJECTIVE

To evaluate temporal trends in deliveries to pregnant individuals with Fontan palliation using nationwide data and to estimate associated obstetric complications among these deliveries.

STUDY DESIGN

Delivery hospitalizations were abstracted from the 2000-2018 Nationwide Inpatient Sample. Fontan deliveries were identified using diagnosis codes and trends in the rates of these deliveries were assessed using joinpoint regression. Baseline demographics and obstetric outcomes (including severe maternal morbidity (SMM), a composite of serious obstetric and cardiac complications) were assessed. Univariable log linear regression models were fit comparing risks of outcomes among deliveries with and without Fontan circulation.

RESULTS

509 pregnancies complicated by Fontan circulation were identified at a rate of 7 per 1 million delivery hospitalizations, with a temporal increase from 2.4 to 30.3 cases per 1 million from 2000 to 2018 (p<0.01). Compared to non-Fontan deliveries, Fontan deliveries were at higher risk of hypertensive disorders (RR 1.79, 95% CI 1.42-2.27), preterm delivery (RR 2.37, 95% CI 1.90-2.96), postpartum hemorrhage (RR 4.28, 95% CI 3.35-5.45), and SMM (RR 6.09, 95% CI 4.54-8.17).

CONCLUSIONS

The rates of deliveries to patients with Fontan palliation are increasing on a national level. These deliveries have higher risks of obstetric complications and SMM. Additional national clinical data are necessary to better understand Fontan pregnancy complications, to improve patient counseling, and to reduce maternal morbidity.

Cesarean Delivery Trends Among Patients at Low Risk for Cesarean Delivery in the US, 2000-2019

Importance

Reducing rates of unnecessary cesarean deliveries is both a national and a global health objective. However, there are limited national US data on trends in indications for low-risk cesarean delivery.

Objective

To determine temporal trends in and indications for cesarean delivery among patients at low risk for the procedure over a 20-year period.

Design, Setting, and Participants

This cross-sectional study analyzed 2000 to 2019 delivery hospitalizations using the National Inpatient Sample. Births at low risk for cesarean delivery were identified using a definition from the Society for Maternal-Fetal Medicine and additional criteria. Temporal trends in cesarean birth were analyzed using joinpoint regression to estimate the average annual percentage change (AAPC) with 95% CIs. Data analysis was performed from August 2022 to January 2023.

Exposure

This analysis evaluated cesarean birth trends in a population at low risk for this procedure over a 20-year period.

Main Outcomes and Measures

In addition to overall cesarean birth risk, cesarean deliveries for nonreassuring fetal status and labor arrest were individually analyzed.

Results

Of an estimated 76.7 million delivery hospitalizations, 21.5 million were excluded according to the Society for Maternal-Fetal Medicine definition, and 14.7 million were excluded according to additional criteria. Of the estimated 40 517 867 deliveries included, 12.1% (4 885 716 deliveries) were by cesarean delivery. Cesarean deliveries among patients at low risk for the procedure increased from 9.7% to 13.9% between 2000 and 2009, plateaued, and then decreased from 13.0% to 11.1% between 2012 and 2019. The AAPC for cesarean delivery was 6.4% (95% CI, 5.2% to 7.6%) from 2000 to 2005, 1.2% from 2005 to 2009 (95% CI, -1.2% to 3.7%), and -2.2% from 2009 to 2019 (95% CI, -2.7% to -1.8%). Cesarean delivery for nonreassuring fetal status increased from 3.4% of all deliveries in 2000 to 5.1% in 2019 (AAPC, 2.1%; 95% CI, 1.7% to 2.5%). Cesarean delivery for labor arrest increased from 3.6% in 2000 to a peak of 4.8% in 2009 before decreasing to 2.7% in 2019. Cesarean deliveries for labor arrest increased during the first half of the study (2000-2009) for the active phase (from 1.5% to 2.1%), latent phase (from 1.1% to 1.5%), and second stage (from 0.9% to 1.3%) and then decreased from 2010 to 2019, from 2.1% to 1.7% for the active phase, from 1.5% to 1.2% for the latent phase, and from 1.2% to 0.9% for the second stage.

Conclusions and Relevance

Cesarean deliveries among patients at low risk for cesarean birth appeared to decrease over the latter years of the study period, with cesarean deliveries for labor arrest becoming less common.

Postpartum stroke trends, risk factors, and associated adverse outcomes

BACKGROUND

Management of postpartum stroke has been the focus of several quality improvement efforts in the past decade. However, there is little recent national trends data for postpartum stroke readmissions.

OBJECTIVE

This study aimed to determine trends, risk factors, and complications associated with postpartum stroke readmission.

STUDY DESIGN

The 2013 to 2019 Nationwide Readmissions Database was used to perform a retrospective cohort study that evaluated the risk for readmission for stroke within 60 days of delivery hospitalization discharge. Temporal trends in readmissions were analyzed using the National Cancer Institute's Joinpoint Regression Program to estimate the average annual percent change with 95% confidence intervals. Stratified trends were analyzed for hemorrhage stroke, ischemic stroke, and stroke readmissions at 1 to 10, 11 to 30, and 31 to 60 days after delivery discharge. Risk factors for stroke were analyzed using unadjusted and adjusted logistic regression models with odds ratios and 95% confidence intervals as measures of association. The risk for stroke complications, including mechanical ventilation, seizures, death, and a prolonged stay ≥14 days, was analyzed.

RESULTS

Of an estimated 21,754,603 delivery hospitalizations, 5006 were complicated by a 60-day postpartum readmission with a diagnosis of stroke. The average annual percent change for all stroke readmissions over the study period was not significant (average annual percent change, 0.1%; 95% confidence interval, -2.2% to 2.4%). When the trends in readmission for ischemic and hemorrhagic stroke were analyzed, the results were similar, as were the stratified analyses by readmission timing. Risk factors associated with increased odds included superimposed preeclampsia (odds ratio, 4.8; 95% confidence interval, 3.9-5.9), preeclampsia with severe features (odds ratio, 3.7; 95% confidence interval, 3.0-4.4), maternal cardiac disease (odds ratio, 3.0; 95% confidence interval, 2.5-3.7), chronic kidney disease (odds ratio, 5.0; 95% confidence interval, 3.4-7.5), and lupus (odds ratio, 7.0; 95% confidence interval, 4.9-10.2). Risk was retained in adjusted analyses. Common stroke-related complications included a prolonged hospital stay ≥14 days (12.1 per 1000 stroke-related readmissions), seizures (9.9 per 1000 stroke-related readmissions), and mechanical ventilation (6.6 per 1000 stroke-related readmissions).

CONCLUSION

This analysis of nationally representative data demonstrated no change in the rate of 60-day postpartum hospitalizations for stroke from 2013 to 2019. Further clinical research is indicated to optimize risk reduction for stroke after delivery hospitalization discharge.

Postpartum psychosis during delivery hospitalizations and postpartum readmissions, 2016-2019

BACKGROUND

Up-to-date data on population-level risk factors for postpartum psychosis is limited, although increasing substance use disorders, psychiatric disorders, autoimmune disorders, and other medical comorbidities in the obstetrical population may be contributing to the increased baseline risk of postpartum psychosis.

OBJECTIVE

This study aimed to determine trends in and risk factors for postpartum psychosis during delivery hospitalizations and postpartum readmissions.

STUDY DESIGN

Analyzing the 2016-2019 Nationwide Readmission Database, this repeated cross-sectional study identified diagnoses of postpartum psychosis during delivery hospitalizations and postpartum readmissions within 60 days of discharge. The relationship among demographic, clinical, and hospital-level factors present at delivery and postpartum psychosis was analyzed with logistic regression models with adjusted odds ratios with 95% confidence intervals as measures of association. Separate models were created for postpartum psychosis diagnoses at delivery and during postpartum readmission. Temporal trends in diagnoses were analyzed with Joinpoint regression to determine the average annual percent change with 95% confidence intervals.

RESULTS

Of 12,334,506 deliveries in the analysis, 13,894 (1.1 per 1000) had a diagnosis of postpartum psychosis during the delivery hospitalization, and 7128 (0.6 per 1000) had a 60-day postpartum readmission with postpartum psychosis. Readmissions with postpartum psychosis increased significantly during the study period (P=.046). Most readmissions with a postpartum psychosis diagnosis occurred in 0 to 10 days (43% of readmissions) or 11 to 20 days (18% of readmissions) after discharge. Clinical factors with the highest adjusted odds for postpartum psychosis readmission included delivery postpartum psychosis (adjusted odds ratio, 5.8; 95% confidence interval, 4.2-8.0), depression disorder (adjusted odds ratio, 3.7; 95% confidence interval, 3.3-4.2), bipolar spectrum disorder (odds ratio, 2.9; 95% confidence interval, 2.3-3.5), and schizophrenia spectrum disorder (adjusted odds ratio, 2.9; 95% confidence interval, 2.1-4.0). In models analyzing postpartum psychosis diagnoses at delivery, risk factors associated with the highest odds included anxiety disorder (adjusted odds ratio, 3.9; 95% confidence interval, 3.5-4.2), schizophrenia spectrum disorder (adjusted odds ratio, 2.5; 95% confidence interval, 1.9-3.4), bipolar disorder (adjusted odds ratio, 1.8; 95% confidence interval, 1.6-2.1), stillbirth (odds ratio, 3.6; 95% confidence interval, 3.1-4.2), and substance use disorder (odds ratio, 1.7; 95% confidence interval, 1.6-1.9). In addition, chronic conditions, such as pregestational diabetes mellitus, obesity, and substance use, were associated with delivery and readmission postpartum psychosis.

CONCLUSION

This study determined that postpartum psychosis is increasing during postpartum readmissions and is associated with a wide range of obstetrical and medical comorbidities. Close follow-up care after delivery for other medical and obstetrical diagnoses may represent an opportunity to identify postpartum psychiatric conditions, including postpartum psychosis.

Characteristics of Individuals in the United States Who Used Opioids During Pregnancy

Background: Opioid use has disproportionally impacted pregnant people and their fetuses. Previous studies describing opioid use among pregnant people are limited by geographic location, type of medical coverage, and small sample size. We described characteristics of a large, diverse group of pregnant people who were enrolled in the Environmental Influences on Child Health Outcomes (ECHO) Program, and determined which characteristics were associated with opioid use during pregnancy. Materials and Methods: Cross-sectional data obtained from 21,905 pregnancies of individuals across the United States enrolled in the ECHO between 1990 and 2021 were analyzed. Medical records, laboratory testing, and self-report were used to determine opioid-exposed pregnancies. Multiple imputation methods using fully conditional specification with a discriminant function accounted for missing characteristics data. Results: Opioid use was present in 2.8% (n = 591) of pregnancies. The majority of people who used opioids in pregnancy were non-Hispanic White (67%) and had at least some college education (69%). Those who used opioids reported high rates of alcohol use (32%) and tobacco use (39%) during the pregnancy; although data were incomplete, only 5% reported heroin use and 86% of opioid use originated from a prescription. After adjustment, non-Hispanic White race, pregnancy during the years 2010-2012, higher parity, tobacco use, and use of illegal drugs during pregnancy were each significantly associated with opioid use during pregnancy. In addition, maternal depression was associated with increased odds of opioid use during pregnancy by more than two-fold (adjusted odds ratio 2.42, 95% confidence interval: 1.95-3.01). Conclusions: In this large study of pregnancies from across the United States, we found several factors that were associated with opioid use among pregnant people. Further studies examining screening for depression and polysubstance use may be useful for targeted interventions to prevent detrimental opioid use during pregnancy, while further elucidation of the reasons for use of prescription opioids during pregnancy should be further explored.

Hospital Admissions from the Emergency Department and Subsequent Critical Care Interventions for Influenza during Pregnancy

OBJECTIVE

The objectives of this study were to determine (1) whether obstetrical patients were more likely to be admitted from the emergency department (ED) for influenza compared with nonpregnant women, and (2) require critical care interventions once admitted.

STUDY DESIGN

Using data from the 2006 to 2011 Nationwide Emergency Department Sample, ED encounters for influenza for women aged 15 to 54 years without underlying chronic medical conditions were identified. Women were categorized as pregnant or nonpregnant using billing codes. Multivariable log linear models were fit to evaluate the relative risk of admission from the ED and the risk of intensive care unit (ICU)-level interventions including mechanical ventilation and central monitoring with pregnancy status as the exposure of interest. Measures of association were described with adjusted risk ratios (aRRs) with 95% confidence intervals (CIs).

RESULTS

We identified 15.9 million ED encounters for influenza of which 4% occurred among pregnant women. Pregnant patients with influenza were nearly three times as likely to be admitted as nonpregnant patients (aRR = 2.99, 95% CI: 2.94, 3.05). Once admitted, obstetric patients were at 72% higher risk of ICU-level interventions (aRR = 1.72, 95% CI: 1.61, 1.84). Of pregnant women admitted from the ED, 9.3% required ICU-level interventions such as mechanical ventilation or central monitoring. Older patients and those with Medicare were also at high risk of admission and ICU-level interventions (p < 0.01).

CONCLUSION

Pregnancy confers three times the risk of admission from the ED for influenza and pregnant women are significantly more likely to require ICU-level medical interventions compared with women of similar age. These findings confirm the significant disease burden from influenza in the obstetric population and the public health importance of reducing infection risk.

KEY POINTS

· Pregnancy confers three times the risk of admission from the ED for influenza.. · Pregnant women admitted with influenza are significantly more likely to require ICU-level care.. · Influenza represents a significant disease burden in the obstetric population.

Risk for adverse maternal outcomes among women with chronic hypertension

OBJECTIVE

To determine whether longitudinal health data accounts for end-organ injury or death in the setting of chronic hypertension.

DESIGN

Cohort of 64 799 deliveries to 61 854 women.

SETTING

US claims data for the preiod 2008-2019.

POPULATION

Women with a delivery hospitalisation and chronic hypertension.

METHODS

Risk for a composite of acute end-organ injury or death during the delivery hospitalisation and 30 days postpartum was analysed. Adjusted logistic regression models were derived with discrimination for each model estimated by the C-statistic. Poisson regression was used to estimate adjusted risk ratios. Starting with models using data from pregnancy, further adjustment was performed accounting for healthcare use in the year prior to pregnancy, including hospitalisations, emergency department encounters, prescription medications and pre-pregnancy diagnoses.

MAIN OUTCOME MEASURES

Acute end-organ injury or death.

RESULTS

The composite outcome occurred among 5.7% of 64 799 deliveries. For patients with commercial insurance, filling non-hypertensive medications from ≥11 different classes, compared with none (adjusted risk ratio, aRR 4.07, 95% CI 2.86-5.79), three or more hospitalisations before pregnancy, compared with none (aRR 4.75, 95% CI 3.46-6.52), and chronic kidney disease diagnosed in the year before pregnancy (aRR 2.35, 95% CI 1.88, 2.94) were associated with increased risk. For pregnancies covered by commercial insurance, the C-statistic increased from 0.615 (95% CI 0.599-0.630) in the model with pregnancy data only to 0.796 (95% CI 0.783-0.808) for the model additionally including healthcare use in the year before pregnancy. Findings with Medicaid were similar.

CONCLUSIONS

Prepregnancy care use predicted adverse maternal outcomes. These data may be important in risk stratification.

Postthrombotic Syndrome and Chronic Pulmonary Embolism after Obstetric Venous Thromboembolism

OBJECTIVE

While the majority of venous thromboembolism (VTE) during pregnancy events resolve with anticoagulation, long-term complications may occur including (1) postthrombotic syndrome and (2) chronic pulmonary embolism. The objective of this study was to determine risk of these two complications.

STUDY DESIGN

A retrospective cohort study using the MarketScan databases was performed on deliveries from 2008 to 2014. We identified women aged 15 to 54 years diagnosed with acute VTE during pregnancy, the delivery hospitalization, or ≤60 days postpartum who received at least one prescription postpartum for anticoagulants. Risks of (1) chronic PE and (2) postthrombotic syndrome were evaluated for women at 6, 12, 24, and 60 months after delivery hospitalization through 2017 via the International Classification of Diseases, 9th/10th Revision, Clinical Modification codes.

RESULTS

Of 4,267 of 4,128,900 pregnancies complicated by VTE, the majority had DVT alone (61.8%, n = 2,637), while 25.8% had PE alone (n = 1,103) and 12.4% (n = 527) had both DVT and PE. Of the entire cohort, 3,328 retained insurance coverage at 6 months, 2,823 at 12 months, 2,161 at 24 months, and 831 at 60 months. Restricted to DVT, risk of postthrombotic syndrome was 0.7% at 6 months (n = 17), 1.1% at 12 months (n = 22), 1.7% at 24 months (n = 26), and 2.7% at 60 months (n = 16). Among women with PE diagnoses, the risk of chronic PE was 2.4% at 6 months (n = 30), 3.3% at 12 months (n = 36), 4.2% at 24 months (n = 36), and 7.2% at 60 months (n = 24).

CONCLUSION

In comparison to the general population, the risk of postthrombotic syndrome was lower. In comparison, the risk of chronic PE was similar to the estimates in the general population at comparable time points after PE events. For women with obstetric PE, it may be appropriate to be vigilant for findings and symptoms associated with chronic PE.

KEY POINTS

· Risk of postthrombotic syndrome after obstetric deep vein thrombosis is low.. · Risk of chronic pulmonary embolism may approximate that in the general population.. · Overall risk of chronic complications after obstetric VTE was relatively low..

Trends in delivery hospitalizations with pregestational and gestational diabetes mellitus and associated outcomes: 2000-2019

BACKGROUND

Pregestational diabetes mellitus and its associated risks may be increasing in the obstetrical population.

OBJECTIVE

This study aimed to characterize the trends in delivery hospitalizations with pregestational diabetes mellitus, the prevalence of chronic diabetes complications, and the risk for adverse outcomes.

STUDY DESIGN

This repeated, cross-sectional study used the United States National Inpatient Sample to identify delivery hospitalizations with pregestational diabetes mellitus between 2000 and 2019. Trends in delivery hospitalizations with pregestational diabetes mellitus were assessed using joinpoint regression to determine the average annual percent change. Trends in chronic diabetes complications, including chronic kidney disease, neuropathy, peripheral vascular disease, and diabetic retinopathy, were also analyzed. The risk for adverse obstetrical outcomes was compared between patients with and those without pregestational diabetes mellitus using adjusted logistic regression models that were adjusted for demographic, clinical, and hospital characteristics with adjusted odds ratios with 95% confidence intervals as measures of association.

RESULTS

Of 76.7 million delivery hospitalizations, 179,885 (0.23%) had type 1 diabetes mellitus, 430,544 (0.56%) had type 2 diabetes mellitus, and 99,327 (0.13%) had unspecified diabetes mellitus. From 2000 to 2019, the prevalence of diabetes mellitus increased from 1.8 to 7.3 per 1000 deliveries for type 2 diabetes mellitus (average annual percent change, 8.0%; 95% confidence interval, 6.9%-9.2%), from 1.5 to 3.2 per 1000 deliveries for unspecified diabetes mellitus (average annual percent change, 3.9%; 95% confidence interval, 1.4%-6.3%), and from 2.7 in 2000 to 2.8 per 1000 deliveries (average annual percent change, 0.2%; 95% confidence interval, -0.8% to 1.3%) for type 1 diabetes mellitus. The prevalence of chronic diabetes mellitus complications increased from 2.7% to 5.6% over the study period (average annual percent change, 5.9%; 95% confidence interval, 3.7%-8.0%). Pregestational diabetes mellitus was associated with severe maternal morbidity, cesarean delivery, hypertensive disorders of pregnancy, preterm birth, and shoulder dystocia.

CONCLUSION

Pregestational diabetes mellitus increased over the study period, driven by a quadrupling in the prevalence of type 2 diabetes mellitus. Notably, the prevalence of chronic diabetes mellitus complications doubled concomitantly. Pregestational diabetes mellitus was associated with a range of adverse outcomes. These findings are further evidence that pregestational diabetes mellitus is an important contributor to maternal risk and that optimizing diabetes care in women of childbearing age will continue to be of major public health importance.

Development of a risk prediction score for acute postpartum care utilization

BACKGROUND

Acute postpartum care utilization and readmissions are increasing in the United States and contribute significantly to maternal morbidity, mortality, and healthcare costs. Currently, there are limited data on the prediction of patients who will require acute postpartum care utilization.

OBJECTIVE

To develop and validate a risk prediction model for acute postpartum care utilization.

STUDY DESIGN

A retrospective cohort study of delivery hospitalizations with a linked birth certificate and discharge records in California from 2011 to 2015 was divided into a training and testing set for analysis and validation. Predictive models for acute postpartum care utilization using demographic, comorbidity, obstetrical complication, and other factors were developed using a backward stepwise logistic regression on training data. A risk score for acute postpartum care utilization was developed using beta coefficients from the factors remaining in the final multivariable model. Risk scores were validated using the testing dataset.

RESULTS

The final sample included 2,045,988 delivery hospitalizations with an acute postpartum care utilization rate of 7.6% in both training and testing cohorts. Twenty-two risk factors were identified for the final multivariable model, including several that were associated with two or more increased odds of acute care utilization (public insurance, postpartum hemorrhage, extremes of maternal age). The mean risk score was 2.45, conferring a 15 times higher risk of acute postpartum care utilization compared to those with a risk score <1 (RR 15.4, 95% CI: 11.0, 21.7). Demographics and test performance characteristics were comparably similar in predictive capability in both models (0.67 in both the training and testing cohorts).

CONCLUSION

Risk factors that are identifiable before discharge can be used to create a cumulative risk score to stratify patients at the lowest and highest risk of acute postpartum care utilization with satisfactory accuracy. External validation and the addition of other granular clinical variables are necessary to validate the feasibility of use.

Trends and outcomes of delivery hospitalizations with unstable housing, 2000-2018

Purpose: Data on trends in and implications of unstable housing during pregnancy are limited. The purpose of this study was to address these knowledge gaps.Methods: This repeat cross-sectional study using the National Inpatient Sample analyzed unstable housing diagnoses among 2000-2018 delivery hospitalizations. Joinpoint regression was used to estimate trends in unstable housing by calculating the average annual percent change.Results: From 2000 to 2018, 27,984 delivery hospitalizations had associated diagnoses of unstable housing (0.03%). There was a significant increase in the unstable housing rates, from 0.72 per 10,000 deliveries in 2000 to 12.8 per 10,000 deliveries in 2018. Delivery hospitalizations with unstable housing were at significantly higher risk of antepartum hemorrhage, preterm delivery, hypertensive disorders of pregnancy, postpartum hemorrhage, and severe maternal morbidity than those without.Conclusions: This serial cross-sectional analysis of delivery hospitalizations found that the reported prevalence of unstable housing is low but increasing and associated with adverse outcomes.

Demographic trends associated with substance use disorder and risk for adverse obstetric outcomes with cannabis and opioid use disorders

BACKGROUND

Substance use disorders (SUDs) are increasing in the obstetric population, vary with demographic characteristics, and are associated with adverse pregnancy outcomes. Cannabis use disorder and opioid use disorder are two of the most common SUDs during pregnancy.

OBJECTIVE

This study had two objectives. The first objective was to assess trends in any SUD diagnosis during delivery hospitalizations from 2000 to 2018 by maternal age, ZIP code income quartile, and hospital location and teaching status. The second objective was to determine risk for adverse pregnancy outcomes during delivery hospitalizations specifically in the presence of cannabis and opioid use disorder diagnoses.

STUDY DESIGN

We conducted a serial cross-sectional analysis of the 2000-2018 National Inpatient Sample. Delivery hospitalizations to women aged 15-54 years with substance use disorder diagnoses were identified. SUD included (i) cannabis use disorder; (ii) opioid use disorder; (iii) alcohol use disorder; and (iv) other drug use disorder. We used joinpoint regression to estimate the average annual percent change (AAPC) in any substance use disorder diagnoses with 95% confidence intervals (CIs) by (i) ZIP code income quartile, (ii) hospital location and teaching status, and (iii) maternal age. We used unadjusted and adjusted log-linear regression to evaluate the relationship between cannabis use disorder and opioid use disorder several adverse maternal outcomes. We report unadjusted and adjusted risk ratios (aRRs) as measures of effect.

RESULTS

From 2000 to 2018, trends analyses broadly demonstrated increasing risk for SUD across demographic categories. In trends analyses stratified by ZIP code-income quartile, the proportion of deliveries with any SUD diagnosis increased across each income quartile with significant increases in the lowest income quartile (AAPC 4.6%, 95% CI 0.4%, 8.9%), second lowest quartile (AAPC 6.3%, 95% CI 5.3%, 7.4%), second highest quartile (AAPC 5.4%, 95% CI 4.1%, 6.8%), and highest quartile (AAPC 4.4%, 95% CI 2.1%, 6.8%). A larger increasing AAPC for SUD was present for deliveries in rural hospitals (AAPC 12.3%, 95% CI 9.8%, 14.9%) as compared to teaching (AAPC 5.7%, 95% CI 5.2%, 6.3%) and non-teaching urban hospitals (AAPC 7.0%, 95% CI 5.9%, 8.1%). By maternal age group, there was a significant larger AAPC for SUD for women aged 15-19 years (AAPC 8.5%, 95% CI 6.6%, 10.4%), 20-24 years (AAPC 9.0%, 95% CI 6.9%, 11.1%) and 25-29 years (AAPC 9.8%, 95% CI 9.1%, 10.6%) than women ≥30 years of age. Cannabis use disorder was associated with increased adjusted risk for preterm delivery (aRR 1.44, 95% CI 1.43, 1.45) and abruption and antepartum hemorrhage (aRR 1.77, 95% CI 1.75, 1.80). Opioid use disorder was associated with risk for non-transfusion severe maternal morbidity (aRR 1.73, 95% CI 1.67, 1.79), preterm delivery (aRR 1.75, 95% CI 1.74, 1.77), and abruption and antepartum hemorrhage (aRR 2.15, 95% CI 2.11, 2.19).

CONCLUSION

While substance use disorders are increasing in pregnancy across rural and urban settings, age groups, and income quartiles, several populations are associated with higher increased risks and trends. These findings support that SUDs are likely to continue to be of public health significance in diverse geographic and demographic settings.

Delivery outcomes associated with maternal congenital heart disease, 2000-2018

PURPOSE

To characterize temporal trends and outcomes of delivery hospitalization with maternal congenital heart disease (CHD).

MATERIALS AND METHODS

For this repeated cross-sectional analysis, deliveries to women aged 15-54 years with maternal CHD were identified in the 2000-2018 National Inpatient Sample. Temporal trends in maternal CHD were analyzed using joinpoint regression to estimate the average annual percentage change (AAPC) with 95% CIs. The relationship between maternal CHD and several adverse maternal outcomes was analyzed with log-linear regression models. Risk for adverse outcomes in the setting of maternal CHD was further characterized based on additional diagnoses of cardiac comorbidity including congestive heart failure, arrhythmia, valvular disease, pulmonary disorders, and history of thromboembolism.

RESULTS

Of 73,109,790 delivery hospitalizations, 51,841 had a diagnosis of maternal CHD (7.1 per 10,000). Maternal CHD rose from 4.2 to 10.9 per 10,000 deliveries (AAPC 4.8%, 95% CI 4.2%, 5.4%). Maternal CHD deliveries with a cardiac comorbidity diagnosis also increased from 0.6 to 2.6 per 10,000 from 2000 to 2018 (AAPC 8.4%, 95% CI 6.3%, 10.6%). Maternal CHD was associated with severe maternal morbidity (adjusted risk ratios [aRR] 4.97, 95% CI 4.75, 5.20), cardiac severe maternal morbidity (aRR 7.65, 95% CI 7.14, 8.19), placental abruption (aRR 1.30, 95% 1.21, 1.38), preterm delivery (aRR 1.47, 95% CI 1.43, 1.51), and transfusion (aRR 2.28, 95% CI 2.14, 2.42). Risk for severe morbidity (AAPC 4.7%, 95% CI 2.5%, 6.9%) and cardiac severe morbidity (AAPC 4.7%, 95% CI 2.5%, 6.9%) increased significantly among women with maternal CHD over the study period. The presence of cardiac comorbidity diagnoses was associated with further increased risk.

CONCLUSION

Maternal CHD is becoming more common among US deliveries. Among deliveries with maternal CHD, risk for severe morbidity is increasing. These findings support that an increasing burden of risk from maternal CHD in the obstetric population.

Trends in and outcomes associated with obstructive sleep apnea during deliveries in the United States, 2000-2019

BACKGROUND

Population-level data on obstructive sleep apnea among pregnant women in the United States and associated risk for adverse outcomes during delivery may be of clinical importance and public health significance.

OBJECTIVE

This study aimed to assess trends in and outcomes associated with obstructive sleep apnea during delivery hospitalizations.

STUDY DESIGN

This repeated cross-sectional study analyzed delivery hospitalizations using the National Inpatient Sample. Temporal trends in obstructive sleep apnea were analyzed using joinpoint regression to estimate the average annual percentage change with 95% confidence intervals. Survey-adjusted logistic regression models were fit to assess the association between obstructive sleep apnea and mechanical ventilation or tracheostomy, acute respiratory distress syndrome, hypertensive disorders of pregnancy, peripartum hysterectomy, pulmonary edema/heart failure, stillbirth, and preterm birth.

RESULTS

From 2000 to 2019, an estimated 76,753,013 delivery hospitalizations were identified, of which 54,238 (0.07%) had a diagnosis of obstructive sleep apnea. During the study period, the presence of obstructive sleep apnea during delivery hospitalizations increased from 0.4 to 20.5 cases per 10,000 delivery hospitalizations (average annual percentage change, 20.6%; 95% confidence interval, 19.1-22.2). Clinical factors associated with obstructive sleep apnea included obesity (4.3% of women without and 57.7% with obstructive sleep apnea), asthma (3.2% of women without and 25.3% with obstructive sleep apnea), chronic hypertension (2.0% of women without and 24.5% with obstructive sleep apnea), and pregestational diabetes mellitus (0.9% of women without and 10.9% with obstructive sleep apnea). In adjusted analyses accounting for obesity, other clinical factors, demographics, and hospital characteristics, obstructive sleep apnea was associated with increased odds of mechanical ventilation or tracheostomy (adjusted odds ratio, 21.9; 95% confidence interval, 18.0-26.7), acute respiratory distress syndrome (adjusted odds ratio, 5.9; 95% confidence interval, 5.4-6.5), hypertensive disorders of pregnancy (adjusted odds ratio, 1.6; 95% confidence interval, 1.6-1.7), stillbirth (adjusted odds ratio, 1.2; 95% confidence interval, 1.0-1.4), pulmonary edema/heart failure (adjusted odds ratio, 3.7; 95% confidence interval, 2.9-4.7), peripartum hysterectomy (adjusted odds ratio, 1.66; 95% confidence interval, 1.23-2.23), and preterm birth (adjusted odds ratio, 1.2; 95% confidence interval, 1.1-1.2).

CONCLUSION

Obstructive sleep apnea diagnoses are increasingly common in the obstetrical population and are associated with a range of adverse obstetrical outcomes during delivery hospitalizations.

Increasing rates of venous thromboembolism among hospitalised patients with inflammatory bowel disease: a nationwide analysis

BACKGROUND

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality among patients with inflammatory bowel disease (IBD). However, data on national trends remain limited.

AIMS

To assess national trends in VTE-associated hospitalisations among patients with IBD as well as risk factors for, and mortality associated with, these events METHODS: Using the U.S. Nationwide Inpatient Sample from 2000-2018, temporal trends in VTE were assessed using the National Cancer Institute's Joinpoint Regression Program with estimates presented as the average annual percent change (AAPC) with 95% confidence intervals (CIs).

RESULTS

Between 2000 and 2018, there were 4,859,728 hospitalisations among patients with IBD, with 128,236 (2.6%) having a VTE, and 6352 associated deaths. The rate of VTE among hospitalised patients with IBD increased from 192 to 295 cases per 10,000 hospitalisations (AAPC 2.4%, 95%CI 1.4%, 3.4%, p < 0.001), and remained significant when stratified by ulcerative colitis (UC) and Crohn's disease as well as by deep vein thrombosis and pulmonary embolism. On multivariable analysis, increasing age, male sex, UC (aOR: 1.30, 95%CI 1.26, 1.33), identifying as non-Hispanic Black, and chronic corticosteroid use (aOR: 1.22, 95%CI 1.16, 1.29) were associated with an increased risk of a VTE-associated hospitalisation.

CONCLUSION

Rates of VTE-associated hospitalisations are increasing among patients with IBD. Continued efforts need to be placed on education and risk reduction.