The patient experience of a postpartum readmission for hypertension: a qualitative study.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) are the most common cause of postpartum readmission. Prior research led to clinical guidelines for postpartum management; however, the patient experience is often missing from this work. The objective of this study is to understand the perspective of patients readmitted for postpartum hypertension. METHODS: This was a qualitative study with data generated through semi-structured interviews. Patients readmitted with postpartum HDP at an urban academic medical center from February to December 2022 were approached and consented for an interview. The same researcher conducted all interviews and patient recruitment continued until thematic saturation was reached (n = 9). Two coders coded all interviews using Nvivo software with both deductive and inductive coding processes. Discrepancies were discussed and resolved with consensus among the two coders. Themes were identified through an initial a priori template of codes which were expanded upon using grounded theory, and researchers were reflexive in their thematic generation. RESULTS: Six themes were generated: every pregnancy is different, symptoms of preeclampsia are easily dismissed or minimized by both patient and providers, miscommunication regarding medical changes can increase the risk of readmissions, postpartum care coordination and readmission logistics at our hospital could be improved to facilitate caring for a newborn, postpartum care is often considered separately from the rest of pregnancy, and patient well-being improved when conversations acknowledged the struggles of readmission. CONCLUSIONS: This qualitative research study revealed patient-identified gaps in care that may have led to readmission for hypertensive disorders of pregnancy. The specific recommendations that emerge from these themes include addressing barriers to blood pressure management prior to discharge, improving postpartum discharge follow-up, providing newborn care coordination, and improving counseling on the risk of postpartum preeclampsia during discharge. Incorporating these patient perspectives in hospital discharge policy can be helpful in creating patient-centered systems of care and may help reduce rates of readmission.

Routine Vaccination During Pregnancy Among People Living With HIV in the United States.

Importance: Pregnancy represents a window of opportunity for vaccination due to established maternal and fetal benefits of vaccination. Little is known about receipt of routinely recommended vaccines in pregnancy, specifically tetanus, diphtheria, plus acellular pertussis (Tdap) and influenza, among pregnant people living with HIV (PLHIV). Objective: To estimate prevalence of vaccination receipt among pregnant people with HIV (PLHIV) and identify demographic and clinical characteristics associated with vaccination. Design, Setting, and Participants: This multicenter cohort study included women participating in Women's Health Study (WHS) of the Surveillance Monitoring for ART Toxicities (SMARTT) Study of the Pediatric HIV/AIDS Cohort Study. The network has been enrolling pregnant PLHIV at 22 US sites since 2007. Participants for this study enrolled between December 2017 and July 2019. Data analysis was conducted from October 2021 to March 2022. Exposure: Data on vaccination in pregnancy were collected through medical record abstraction. Main Outcomes and Measures: Vaccination receipt was defined as Tdap vaccination received at less than 36 weeks' gestation and influenza vaccination at any gestational age, based on current guidelines. Log-binomial and modified Poisson regression models with generalized estimating equations were fit to identify factors associated with successful receipt of (1) Tdap, (2) influenza, and (3) both vaccinations. Results: A total of 310 pregnancies among 278 people participating in the WHS were included (mean [SD] age, 29.5 [6.1] years; 220 [71%] Black, 77 [25%] Hispanic, and 77 [25%] race and ethnicity other than Black; 64 [21%] with perinatally acquired HIV). Less than one-third of pregnancies were vaccinated as recommended (Tdap, 32.6% [95% CI, 27.4%-38.1%]; influenza, 31.6% [95% CI, 26.5%-37.1%]; both, 22.6% [95% CI, 18.0%-27.6%]). People living with perinatally acquired HIV, those who did not identify as Black, or those who were multiparous had adjusted risk ratios (aRRs) less than 1, while older PLHIV had aRRs greater than 1, but these differences did not reach statistical significance (perinatally acquired HIV: adjusted risk ratio [aRR], 0.46; 95% CI, 0.21-1.02; race other than Black: aRR, 0.53; 95% CI, 0.26-1.08; multiparous: aRR, 0.59; 95% CI, 0.35-1.00; age 24-29 years: aRR, 2.03; 95% CI, 0.92-4.48). Conclusions and Relevance: In this diverse, multicenter cohort of pregnant PLHIV, receipt of recommended vaccinations was low. Identifying and addressing barriers to vaccination receipt is urgently needed for pregnant people with HIV.

Redesigning Care for the Management of Postpartum Hypertension: How Can Ob-Gyns and Primary Care Physicians Partner in Caring for Patients after a Hypertensive Pregnancy?

The standard care model in the postpartum period is ripe for disruption and attention. Hypertensive disorders of pregnancy (HDPs) can continue to be a challenge for the postpartum person in the immediate postpartum period and is a harbinger of future health risks. The current care approach is inadequate to address the needs of these women. We propose a model for a multidisciplinary clinic and collaboration between internal medicine specialists and obstetric specialists to shepherd patients through this high-risk time and provide a bridge for lifelong care to mitigate the risks of a HDP. KEY POINTS: · HDPs are increasing in prevalence.. · The postpartum period can be more complex for women with HDPs.. · A multidisciplinary clinic could fill the postpartum care gap for women with HDP..

Evaluation of State-Mandated Third Trimester Repeat HIV Testing in a Large Tertiary Care Center.

OBJECTIVE: The Illinois Perinatal HIV Prevention Act was passed to ensure universal HIV testing once during pregnancy and was extended in 2018 to add third trimester repeat HIV screening. The objectives of this analysis were to describe uptake of, and patient factors associated with, third trimester repeat HIV testing at a high-volume birthing center. STUDY DESIGN: This is a retrospective cohort study of people who delivered at a single tertiary care hospital in Illinois during 2018. Women who delivered before 27 weeks, had an intrauterine fetal demise, a known diagnosis of HIV, or no HIV test during pregnancy were excluded. Repeat testing was defined as an HIV test at or after 27 weeks' gestation after an earlier negative HIV test during the same pregnancy. The primary outcome was the proportion of people who received repeat testing prior to delivery. Bivariable analyses were performed to identify patient characteristics associated with documentation of repeat HIV testing. RESULTS: Of 12,053 people eligible for inclusion, 3.4% (n = 414) presented without a documented third trimester repeat HIV test. The proportion of people with repeat testing improved from 80 to >99% in the first year. Patient factors were largely not associated with testing performance although multiparous people were more likely to have documented repeat testing. CONCLUSION: Rapid implementation of third trimester repeat HIV testing was achieved without disparity. Patient factors were largely not associated with testing performance which reinforces the goal of a universal screen to test all people equitably and effectively without bias. KEY POINTS: · Little is known about adherence to repeat third trimester HIV testing in pregnancy.. · Universal third trimester HIV screening was implemented with high uptake and without disparity.. · Protocolization of repeat HIV testing in pregnancy may reduce bias compared to risk based-screening..

Association between weighted adverse outcome score and race/ethnicity in women and neonates.

OBJECTIVE: To examine the association between the Weighted Adverse Outcome Score (WAOS) and race/ethnicity among a large and diverse population-based cohort of women and neonates in the United States. STUDY DESIGN: This was a retrospective cohort study of women who delivered in the United States between 2011 and 2013. We identified mother-infant pairs with adverse maternal and/or neonatal outcomes. These outcomes were assigned weighted scores to account for relative severity. The association between race/ethnicity and WAOS was examined using chi-square test and multivariable logistic regression. RESULTS: Compared to White women and their neonates, Black women and their neonates were at higher odds of an adverse outcome. CONCLUSION(S): The vast majority of women and neonates had no adverse outcome. However, Black women and their neonates were found to have a higher WAOS. This tool could be used to designate hospitals or regions with higher-than-expected adverse outcomes and target them for intervention.

Home Birth in the Era of COVID-19: Counseling and Preparation for Pregnant Persons Living with HIV.

With the coronavirus disease 2019 (COVID-19) pandemic in the United States, a majority of states have instituted "shelter-in-place" policies effectively quarantining individuals-including pregnant persons-in their homes. Given the concern for COVID-19 acquisition in health care settings, pregnant persons with high-risk pregnancies-such as persons living with HIV (PLHIV)-are increasingly investigating the option of a home birth. Although we strongly recommend hospital birth for PLHIV, we discuss our experience and recommendations for counseling and preparation of pregnant PLHIV who may be considering home birth or at risk for unintentional home birth due to the pandemic. We also discuss issues associated with implementing a risk mitigation strategy involving high-risk births occurring at home during a pandemic. KEY POINTS: · Coronavirus disease 2019 pandemic has increased interest in home birth.. · Women living with HIV are pursuing home birth.. · Safe planning is paramount for women living with HIV desiring home birth, despite recommending against the practice..

The Reproductive Years of Women with Perinatally Acquired HIV: From Gynecologic Care to Obstetric Outcomes.

Women with PHIV have distinct medical and social concerns in the context of lifelong immunosuppression, complex HIV care, and stigma because of with HIV from an early age. This article reviews the gynecologic and obstetric concerns experienced by women with PHIV. Cervical cancer screening is suboptimal, and data suggest higher rates of unintended pregnancy. Pregnant women with PHIV are younger and exposed to more antiretroviral therapy regimens compared with women with NPHIV. Although obstetric outcomes are similar between women with PHIV and NPHIV, there are concerns that infant morbidity may be increased in infants of women with PHIV.

Disparities in 17-Hydroxyprogesterone Caproate Offer and Uptake in Pregnancies at a Risk of Preterm Birth.

OBJECTIVE: To evaluate the offer, acceptance, uptake, and patient experience with 17-hydroxyprogesterone caproate (17OHP-C) over the course of 10 years. STUDY DESIGN: This is a retrospective cohort study with a qualitative component. We identified all women with spontaneous preterm deliveries with subsequent births in our hospital between 2005 and 2015. We used linear regression to calculate unadjusted odds ratios for 17OHP-C offer, acceptance, and doses received associated with predictors of interest, and multivariable modeling further adjusted for potential confounders. A grounded theory approach was used to glean recurrent themes surrounding the patient experience. RESULTS: A total of 265 women fit the eligibility criteria; 39.6% were offered 17OHP-C and 83.8% accepted 17OHP-C. The mean number of documented 17OHP-C doses was 15.7 ± 5.4. Women were less likely to be offered 17OHP-C if they had public insurance or if their earliest preterm birth was of greater gestational age. Non-Hispanic black women were documented to have received four fewer doses than white women. We also identified recurrent themes that hindered acceptance and adherence to 17OHP-C: insurance difficulties, unstable housing, lack of childcare, and job inflexibility. CONCLUSION: Women at a risk of preterm birth are more likely to be offered and receive 17OHP-C if they have private insurance and have had an earlier preterm birth. Non-Hispanic black women were documented to have received fewer doses of 17OHP-C than white women. Further inquiry into the structural causes that lead to disparities in care for women at a risk for preterm birth is important.

Mucinous differentiation does not impact stage or risk of recurrence among patients with grade 1, endometrioid type, endometrial carcinoma.

OBJECTIVE: To evaluate whether the presence of mucinous differentiation influences histopathologic findings, stage distribution, or rate of recurrence among women with grade 1, endometrioid type, endometrial carcinoma. METHODS: This was a retrospective cohort study of all patients with grade 1, endometrioid type, endometrial carcinoma between January 2005 and December 2012. Patients were separated by the presence or absence of mucinous differentiation and then compared. RESULTS: Of 655 patients, mucinous differentiation was present in 137 (20.9%) and absent in 518 (79.1%) patients. Compared to the group without mucinous differentiation, the group containing mucinous differentiation was older at diagnosis (mean: 61.1 vs. 58.5 years, OR, 95% CI; 1.03, 1.01-1.05) and more likely to have myometrial invasion (61.3% vs. 51.5%, OR, 95% CI; 1.49, 1.01-2.19). Additional histopathologic findings including: tumor size, cervical stromal invasion, adnexal involvement, LVI and/or the presence of positive lymph nodes were similar between groups. Mucinous differentiation did not affect stage distribution, as most patients were stage 1A (85.4% vs. 86.3%). The median PFS for the entire group has yet to be reached. The mean PFS for the entire study sample was 94.7 months. There was no difference in mean PFS when comparing the group with mucinous differentiation to the group without mucinous differentiation (98 vs. 93.4 months, p=0.07). CONCLUSIONS: In the setting of grade 1, endometrioid type, endometrial carcinoma, mucinous differentiation is more common in older patients and is associated with an increased likelihood of myometrial invasion. However, stage distribution and risk of recurrence are not affected.

Using standardized videos to validate a measure of handoff quality: the handoff mini-clinical examination exercise.

BACKGROUND: The most recent iteration of the Accreditation Council for Graduate Medical Education duty-hour regulations includes language mandating handoff education for trainees and assessments of handoff quality by residency training programs. However, there is a lack of validated tools for the assessment of handoff quality and for use in trainee education. METHODS: Faculty at 2 sites (University of Chicago and Yale University) were recruited to participate in a workshop on handoff education. Video-based scenarios were developed to represent varying levels of performance in the domains of communication, professionalism, and setting. Videos were shown in a random order, and faculty were instructed to use the Handoff Mini-Clinical Examination Exercise (CEX), a paper-based instrument with qualitative anchors defining each level of performance, to rate the handoffs. RESULTS: Forty-seven faculty members (14 at site 1; 33 at site 2) participated in the validation workshops, providing a total of 172 observations (of a possible 191 [96%]). Reliability testing revealed a Cronbach α of 0.81 and Kendall coefficient of concordance of 0.59 (>0.6 = high reliability). Faculty were able to reliably distinguish the different levels of performance in each domain in a statistically significant fashion (ie, unsatisfactory professionalism mean 2.42 vs satisfactory professionalism 4.81 vs superior professionalism 6.01, P < 0.001 trend test). Two-way analysis of variance revealed no evidence of rater bias. CONCLUSIONS: Using standardized video-based scenarios highlighting differing levels of performance, we were able to demonstrate evidence that the Handoff Mini-CEX can draw reliable and valid conclusions regarding handoff performance. Future work to validate the tool in clinical settings is warranted.