Mothers at Risk: Factors Affecting Maternal Postpartum Length of Stay.

Perinatal complications linked to maternal comorbidities contribute to increased healthcare utilization through an extended postpartum length of stay (LOS). Understanding factors influencing postpartum LOS may minimize the adverse effects associated with comorbidities and complications. The purpose of this study was to identify risk factors with the greatest odds of increasing postpartum LOS. Linked 2008-2009 hospital discharge and birth certificate data were used to examine comorbidities and complication codes in 1 015 424 births. The overall rate for an extended LOS (vaginal: >5 days/cesarean: >6 days) was 3.63 per 1000 live births. Complications were present in 17% of pregnancies; multiple complications were seen in 1%. Chronic hypertension was associated with an extended stay for both vaginal and cesarean births (odds ratio [OR] = 5.89 [95% CI, 4.39-7.88]; OR = 3.57 [95% CI, 3.05-4.17], respectively). Puerperal infections (OR = 6.86 [95% CI, 5.73-8.21]), eclampsia (OR = 17.07 [95% CI, 13.76-21.17]), and transfusions (OR = 11.66 [95% CI, 9.20-14.75]) occurred most frequently and conferred the highest odds of an extended stay for vaginal births. Cerebrovascular conditions (OR = 15.32 [95% CI, 11.90-19.60]) and infection (OR = 15.35 [95% CI, 10.11-23.32]) conferred the highest odds of an extended LOS for cesarean births. The earlier risk factors are recognized, the sooner processes can be initiated to optimize organizational preparation, thus decreasing adverse maternal outcomes and extended hospital stays.

Disparities in Cardiovascular Disease Outcomes Among Pregnant and Post-Partum Women.

Background The incidence of cardiovascular disease among pregnant women is rising in the United States. Data on racial disparities for the major cardiovascular events during pregnancy are limited. Methods and Results Pregnant and post-partum women hospitalized from January 2007 to December 2017 were identified from the Nationwide Inpatient Sample. The outcomes of interest included: in-hospital mortality, myocardial infarction, stroke, pulmonary embolism, and peripartum cardiomyopathy. Multivariate regression analysis was used to assess the independent association between race and in-hospital outcomes. Among 46 700 637 pregnancy-related hospitalizations, 21 663 575 (46.4%) were White, 6 302 089 (13.5%) were Black, and 8 914 065 (19.1%) were Hispanic. The trends of mortality and stroke declined significantly in Black women, but however, were mostly unchanged among White women. The incidence of mortality and cardiovascular morbidity was highest among Black women followed by White women, then Hispanic women. The majority of Blacks (62.3%) were insured by Medicaid while the majority of White patients had private insurance (61.9%). Most of Black women were below-median income (71.2%) while over half of the White patients were above the median income (52.7%). Compared with White women, Black women had the highest mortality with adjusted odds ratio (aOR) of 1.45, 95% CI (1.21-1.73); myocardial infarction with aOR of 1.23, 95% CI (1.06-1.42); stroke with aOR of 1.57, 95% CI (1.41-1.74); pulmonary embolism with aOR of 1.42, 95% CI (1.30-1.56); and peripartum cardiomyopathy with aOR of 1.71, 95 % CI (1.66-1.76). Conclusions Significant racial disparities exist in major cardiovascular events among pregnant and post-partum women. Further efforts are needed to minimize these differences.

Description and classification of postpartum chronic pain: A multicentric prospective study.

INTRODUCTION: To classify persistent perineal and pelvic postpartum pain using the classification usually employed in chronic pelvic pain. MATERIAL AND METHOD: Prospective observational study including all women who have consulted an algologist or gynecologist at one of the six French centers for a chronic pain (superior or equal to 3 months) spontaneous linked by the mother with her childbirth were included. During semi-directed interviews, a questionnaire regarding sociodemographic factors and detailed questions about pain were collected. Then, pelvic and perineal pain were classified into 7 pain syndromes: pelvic sensitization (Convergences PP criteria), complex regional pain syndrome (Budapest criteria), pudendal or cluneal neuralgia (Nantes criteria), neuroma, thoraco-lumbar junction syndrome, myofascial pain (muscle trigger zone), fibromyalgia (American College of Rheumatology criteria). The principal objective of this study is to assess the prevalence of each painful disorder. The secondary aims were the description of socio-demographic factors and clinical characteristics of this population, identify the related symptoms and the impact on daily function associated with the chronic pelvic or perineal postpartum pain. RESULTS: 40 women with chronic pelvic or perineal pain spontaneously linked with childbirth were included. 78 % experienced pain for more than 12 months. A large majority had a vaginal birth (95 %) with perineal suture (90 %) and severe acute pain within the first week postpartum (62 %). Postpartum pain impacted participant's sexual activity (80 %), micturition (28 %) and defecation (38 %). In the sample, 17 cases of neuroma, 6 patients with pudendal or cluneal neuralgia, 13 patients with pelvic sensitization and 2 cases of fibromyalgia were identified. Complex regional pain syndrome was diagnosed in 8 patients, and myofascial pain in 11 women, and only 1 patient had thoraco-lumbar junction syndrome. Neuropathic pain was found in 31 participants (77.5 %) according to DN4 criteria. DISCUSSION: The classification scheme proposed in this study may be a very useful tool to investigate postpartum pelvic and perineal pain and to propose a treatment.

[Bipolar disorder, pregnancy and the postpartum--risks and possibilities of pharmacotherapy]. / Psychopharmaka in Schwangerschaft und Stillzeit--Risiken und Möglichkeiten bei Frauen mit einer bipolaren affektiven Störung.

Pregnancy and the postpartum are times of increased risk for women with bipolar disorder to develop mood episodes, especially depressions that may require pharmacotherapy. If mood stabilizing agents are discontinued prior or due to pregnancy, the risk for relapse increases dramatically. On the other hand, there is no psychotropic drug that is completely risk-free for the unborn. Some mood stabilizing medications are teratogenic, others can cause severe perinatal complications. Thus, the decision whether to treat the pregnant women with psychotropic drugs is difficult to make. In this paper, the reproductive risks of mood stabilizing agents, antidepressants, neuroleptics and benzodiazepines for the fetus are reviewed. During the postpartum period severe mood disorders can occur. The signs and symptoms of these disorders are reviewed and therapeutic strategies are discussed.

A latent class analysis of brief postpartum psychiatric hospital admissions.

Almost 40% of postpartum psychiatric hospital admissions are brief, lasting 72h or less. We aimed to identify unique subgroups of women within this group to inform better intervention. All women in Ontario, Canada with a brief postpartum psychiatric admission (≤ 72h) (2007-2012)(N = 631) were studied using latent class analysis. We identified distinct subtypes of women and compared women within each subtype on post-discharge mental health indicators: physician visits, emergency department (ED) visits and readmissions. We identified four clinically distinct classes: (1)women with no diagnosed mental illness (2 years before delivery) (n = 179; 28.4% of the sample); (2)women with pre-existing history of severe mental illness (i.e. psychosis) (n = 161; 25.5%); (3)women with pre-existing history of non-psychotic mental illness (n = 211; 33.4%); and (4)adolescent rural-dwelling women with alcohol and substance use disorders (n = 80; 12.7%). In the 1 year post-discharge, women in classes 1-3 were more likely to have post-discharge physician visit than women in class 4 (p < 0.05) and were less likely to have a psychiatric ED visit (p < 0.05). Women in class 2 were most likely to be readmitted (p < 0.05). We identified clinically distinct subgroups of women with brief postpartum psychiatric admissions who may each benefit from differing targeted preventive strategies and post-discharge treatment planning.

A review of medical records and discharge summary data found moderate to high predictive values of discharge diagnoses of venous thromboembolism during pregnancy and postpartum.

OBJECTIVE: To validate the discharge diagnoses of venous thromboembolism during pregnancy and postpartum, we examined the positive predictive value (PPV) of venous thromboembolic (VTE) discharge diagnoses associated with pregnancy or puerperium based on 311 cases registered in a Danish population-based hospital-discharge registry. STUDY DESIGN AND SETTING: Medical records and hospital discharge summaries were retrieved and reviewed using a standardized form. Standard and pregnancy-specific codes were used for 147 (49%) and 153 (51%) cases, respectively. RESULTS: The overall PPV of the selected codes was 87.3% (95% confidence interval [CI]: 83.0-90.9). When focusing on confirmed VTE events in relation to the pregnancy, the overall PPV was 79.3% (95% CI: 74.3-83.8). CONCLUSION: The overall PPVs of pregnancy-related VTE diagnoses were moderate to high. The predictive values varied substantially between the individual codes, however, and not all the registered VTE events occurred in relation to pregnancy. Thus, use of unvalidated registry-based pregnancy-related VTE diagnoses for epidemiological research may lead to biased results.

Delivery-related complications and early postpartum morbidity in Dhaka, Bangladesh.

OBJECTIVE: To describe delivery-related complications and postpartum morbidity of women living in slum areas of Dhaka, Bangladesh. METHOD: From November 1993 to May 1995, 1506 women were interviewed regarding delivery-related complications and postpartum morbidities. Operational definitions were applied to maternal reports to categorize serious delivery-related complications and postpartum morbidity. Corroborating information was identified from medical records for facility-based deliveries and physical examinations by female physicians 14 to 22 days postpartum. RESULT: Thirty-six percent of women described serious delivery-related complications and 75% of women reported postpartum morbidity. There were two maternal deaths among 1471 live births. When maternal reports were related to corroborating information, the proportion of women's reports of serious complications and morbidity appears reasonably accurate for some conditions. CONCLUSION: A large proportion of urban slum women in Dhaka experience serious delivery-related complications and/or postpartum morbidity. Information on delivery practices that contribute to morbidity and factors that influence appropriate care seeking is needed.

[Mental disorders during pregnancy and postpartum period--epidemiology, etiology, classification and treatment]. / Zaburzenia psychiczne okoloporodowe--epidemiologia, etiologia, klasyfikacja, leczenie.

The paper presents current knowledge about the prevalence of mental disorders during pregnancy and postpartum period and its' classification. Possible pathomechanisms of its incidence, risk factors and therapeutic possibilities based on the newest research were described.

Postpartum cardiac failure in Sudanese-Sahelian Africa: clinical prevalence in western Niger.

Postpartum cardiac failure (PPCF) is the most frequent clinical form of heart failure in hospitalized women in Sudanese-Sahelian Africa. We have previously studied this disease in a hospital setting. Although the incidence is relatively high in rural areas, no systematic field study has been carried out. In this report, we describe a retrospective study conducted in the western part of Niger in July-August 1991. Sixty-two villages were visited and a thorough search for patients was initiated (from a population of 79,941 inhabitants, 19,941 females 14-40 years of age, corrected census of 1988). Twenty-eight patients from 27 villages were included. The subject patients were those presenting with predefined symptoms (dyspnea and cough) and physical signs (edema of the legs) of congestive heart failure during the six-month period following delivery. Apart from arterial hypertension and previous PPCF, diagnosis of another cardiac disease was an exclusion criterion. The prevalence of PPCF was 1.40 per 1,000 females of child-bearing age. The clinical profiles of these cases were in accordance with those of a previous study in 1989 carried out at Niamey Hospital. These results were a mean +/- SD age of 28 +/- 7 years, multiparity (mean = 4 children), poor socioeconomic status, postpartum ablutions with hot water, and a high sodium intake. This is the first study on the clinical prevalence of PPCF in a Sudanese/Sahelian population living in a rural area.

PIP: A descriptive retrospective study conducted in 62 villages in Western Niger in July-August 1994, examined the prevalence of postpartum cardiac failure (PCF). This condition, the most frequent clinical form of heart failure in hospitalized women in Sudanese-Sahelian Africa, has not previously been investigated in a field study. Meetings with village leaders were used to identify women who had just given birth and those who were ill. Through this method, 60 ill women who had given birth in the preceding 9 months were identified. PCF was diagnosed in 28 of these women from 27 villages on the basis of predefined symptoms (dyspnea and cough) and physical signs (edema of the legs) of congestive heart failure during the 6 months after delivery. The prevalence of PCF was 1.40/1000 women of childbearing age; likely an underestimate since the field identification criteria did not take into account women who had already died. The mean age of identified patients was 28 years, with a mean parity of 4. Low socioeconomic status, postpartum ablutions with hot water, and a high sodium intake were common in these women. A comparison of 17 clinical and epidemiological factors in this series with those of 66 patients who previously had PCF confirmed at Niamey National Hospital did not reveal any significant differences in the incidence of symptoms between the 2 groups, although functional discomfort was more severe in the hospital study. Untreated cardiac failure is usually a fatal disease. Timely identification of PCF is hindered, however, by well-tolerated symptoms.

Does puerperal illness distinguish a subgroup of bipolar patients?

Puerperal psychosis was found to be the 1st illness for 13 (36%) of a series of 36 mothers with bipolar affective disorder. The risk of recurrence with childbirth in those with established bipolar disorder was found to be 25-40%. Those women who survived childbirth without illness but then became ill at a later time reported a worse illness course. Recent fatherhood was not a precipitant of 1st affective illness for any of the 28 bipolar men.

An epidemiological and clinical investigation of postpartum psychiatric illness in Japanese mothers.

A case note study of postpartum psychiatric illness as defined by Research Diagnostic Criteria (RDC) was conducted in an epidemiologically defined large area of Japan. The admission rate was 0.34/1000 live births. The most frequent diagnostic category was affective disorder (53%). "Atypical" symptoms were observed in 31% of all cases and were more frequent (67%) in patients with schizoaffective disorder. Fifty six percent of mothers developed a psychiatric illness within two weeks of delivery. The patients with "atypical" symptoms were admitted much more quickly and their length of stay in hospital was shorter.

Symptomatology of affective and psychotic illnesses related to childbearing.

Symptom patterns in women with childbearing-related onset illnesses (CBROI) and nonchildbearing-related onset illnesses (NCBROI) were compared. Women with diagnoses of Affective Disorders and Psychoses (n = 762) were divided into four groups: CBROI with psychosis, CBROI with non-psychotic affective illnesses, NCBROI with psychosis, and NCBROI with non-psychotic affective illness. Principal components analysis of 64 symptoms revealed 9 factors. The most dramatic result was the high score for psychotic women with CBROI on the factor cognitive disorganization/psychosis. Psychotic women with CBROI also reported homicidal ideation more frequently. Symptoms of non-psychotic women with CBROI and NCBROI did not differ.

Surgical implications of ovarian vein thrombosis.

Ovarian vein thrombosis, with rare exceptions, is a puerperal process that often mimicks appendicitis but may be recognized only in retrospect as a source of continued pulmonary embolization. Ovarian vein thrombosis may also accompany septic pelvic thrombophlebitis and constitute a life-threatening problem. Ovarian vein thrombosis probably exists in a subclinical form as well, and the relative infrequency of reports of this entity attest to the lack of clinical recognition rather than to its clinical rarity. Most instances of ovarian vein thrombosis will respond to antibiotics, anticoagulation, hydration and bed rest but, when septic in etiology, interruption of the vena cava and ovarian veins may be required. Acute appendicitis, the most frequent misdiagnosis, often leads to exploration, and careful resection of the affected vein in such patients generally results in cure.

Surgical classification of obstetric fistulas.

OBJECTIVE: To develop a surgical classification for obstetric fistulas in order to compare surgical techniques and results. METHODS: Based on a retrospective analysis of 775 consecutive fistula patients, the following classification is presented: (type I) fistulas not involving the urethral closing mechanism; (type II) fistulas involving the urethral closing mechanism; and (type III) ureter and other exceptional fistulas. Type II fistulas can be further divided into: (A) without (sub)total urethra involvement, and (B) with (sub)total urethra involvement; and (a) without a circumferential defect, and (b) with a circumferential defect. This classification was applied prospectively in over 2700 consecutive fistula patients. RESULTS: The surgical technique becomes progressively more complicated from type I through type IIBb. The results of closure and continence worsen progressively from type I through type IIBb. Personal experience in the case of type III fistulas is very limited. CONCLUSION: This classification enables a systematic comparison of different surgical techniques and an objective evaluation of results from different centers.

[Todani type I choledochal cyst--diagnosis and surgical therapy]. / Die Choledochuscyste Typ I nach Todani--Diagnostik und chirurgische Therapie.

Ultrasound, ERC and computed tomography are the main preoperative diagnostic procedures of common bile duct cysts. In individual cases the definitive diagnosis can be confirmed only intraoperatively. The high rate of complications and the risk of carcinoma requires a radical surgical treatment.

Psychiatric disorders in the puerperium. A follow-up study.

The outcome of puerperal psychoses in a group of 66 patients was studied 10-11 years after the initial illness. The present health of the study group and a control non-puerperal group was compared using the Health Sickness Rating Scale (HSRS). The majority of the puerperal psychotics were primigravida. The rate of positive family history of psychiatric illness was similar in both groups. There was no significant difference in the scores of both group on the H.S.R.S. A startling finding was a mortality of 1 in 5 amongst the puerperal psychotics. These and other findings are discussed.

[The perinatal period and pediatric psychiatry. Reflections on the interworking of a maternity department]. / Périnatalité et pédopsychiatrie. Réflexions sur la travail d'un inter-secteur dans une maternité.

This work is an assessment of the results of routine meetings between a children's psychiatrist and mothers with their new born babies in a general district hospital's maternity department. The approach is to look for early detection of faults in the mother-child relationship. Difficulties can be grouped into simple categories. The presence of a paediatric psychiatrist in a maternity department has made it possible to show up the value of specialised help early on as much for the 25% of women who are distressed after delivery as for the 6-7% that are really worrying cases.

[Acute puerperal uterine inversion: two cases]. / Inversion utérine puerpérale aiguë: à propos de deux cas.

Acute puerperal inversion is both rare and serious (1/20000 deliveries in France) and may lead to significant morbidity and mortality. Outcome depends on the degree of uterine bleeding and the presence or not of a state of shock. Acute puerperal inversion occurs at the time of placental delivery. Four stages are usually described by degree of exteriorization of the uterus. The diagnosis is essentially clinical. The predisposing factors are hypotonic uterus, fundal implantation of the placenta and placental acretas. 60% of all cases are caused by precipitous manoeuvres including traction on the cord or improper fundal pressure. Once a diagnosis is made immediate measures must be undertaken to assure clinical stability of the mother. Manuel reinversion of the uterus must be done quickly to avoid a cervical stricture that may form within thirty minutes of the inversion making successful manipulation very difficult. Failure or reoccurrence requires surgical treatment either by abdominal or vaginal approach. We report on two cases: one of complete inversion leading to a hysterectomy in order to control bleeding and a second case of incomplete inversion where repositioning was successful.

Puerperal uterine inversion.

Puerperal uterine inversion, a life threatening condition, is a true obstetrical emergency. Quick reanimation measures coupled with manual or surgical correction are the key to success in managing this rare condition.

[Interobserver variation in the classification of diseases]. / Interobservatørvariationen ved klassifikation af sygdomme.

The aim of this study was to describe the variation between observers in classification of diseases, with special regard to pregnancy, birth and maternity. Four observers A, B, C and D classified 150 random cases of pregnancy, birth and maternity. The rate of agreement between the observers and their use of diagnosis was evaluated. The total agreement-rate was 58% concerning diagnoses of pregnancy, 82% concerning maternity and 13% concerning delivery; with variation between the observers at 71-85%, 86-96% and 26-54%. The diagnostic spectrum of the observers and their criteria for the use of diagnoses were variable. In conclusion, great variation was found between observers in classifying diseases, due to different diagnostic criteria being used by the observers, and due to misunderstanding of the Classification of Diseases. The setting-up of committees of branch-specialists is recommended, if we in the future want to use a public diagnostic register as a tool for research. These committees must achieve consensus concerning the need for classification within each specialty, define criteria of diagnosis and effect recommendation or education in the system of classification.