Venous Thromboembolism Prophylaxis Should Be Recommended for Antepartum Admissions and Cesarean Delivery if Age and Body Mass Index are Greater Than 35.

OBJECTIVE: Venous thromboembolism (VTE) is a major cause of maternal morbidity and mortality. Current expanded treatment recommendations result in the inclusion of a large percentage of the obstetric population, which has limited their adoption. The purpose of this study was to identify a population at high risk for VTE, with minimal impact on the number of patients that would qualify for expanded treatment. STUDY DESIGN: We performed a retrospective analysis of a large obstetric population. International Classification of Diseases, 10th Revsion (ICD-10) codes for VTE were used to identify patients presenting for obstetric or postpartum (PP) care from January 2016 to March 2018. The review focused on high-risk factors (history of VTE or high-risk thrombophilia), antepartum hospital admissions that were >72 hours in the previous 30 days, use of sequential compression devices, body mass index (BMI; kg/m2), age, and mode of delivery. Pharmacologic treatment efficacy was set at 90, 75, or 50%. RESULTS: During the 27-month review period, there were 120,235 deliveries and 93 had a VTE event in the index pregnancy or within 4 weeks PP (7.7/10,000 births). A history of VTE or high-risk thrombophilia was seen in 25.8% of cases. Antepartum admission was noted in 40.9%, and the combination of cesarean delivery (CD) with age and BMI ≥35 (Age + BMI + CD) was noted in 17.3% of PP cases. Targeting these latter two groups for VTE prophylaxis with a 75% efficacy suggests that 34% of the VTE events would likely have been prevented while increasing the total population treated by approximately 2%. CONCLUSION: Expanding pharmacologic prophylactical coverage to include an antepartum admission of >72 hours and those with Age + BMI + CD would result in about a one-third reduction in total VTE events with about 2% requiring treatment. These data support some of the suggested recommendations for expanded pharmacological deep venous thrombosis prophylaxis. KEY POINTS: · CD, and BMI and age >35 are high-risk factors for VTE.. · Antepartum admission >72 hours is a high-risk factor for VTE.. · Targeting antepartum admissions, CD, and BMI and age >35 would reduce VTE events by about 33%..

Effectiveness of the Intrauterine Balloon Tamponade Compared With an Intrauterine, Vacuum-Induced, Hemorrhage-Control Device for Postpartum Hemorrhage.

OBJECTIVE: To compare intrauterine balloon tamponade and vacuum-induced hemorrhage-control devices in a multicenter hospital system using a standardized three-stage postpartum hemorrhage response algorithm. METHODS: As part of a quality improvement project, data were prospectively collected through ongoing detailed hemorrhage case audits from 65 facilities from August 2022 to February 2024. Postpartum hemorrhage-control devices are recommended for stage 2 or 3 of the postpartum hemorrhage algorithm. The primary outcomes were 1) quantitative blood loss after device placement, 2) rate of packed red blood cell (RBC) transfusion, 3) use of 3 units of packed RBCs or more, and 4) device failure. RESULTS: During the 17-month observation period, there were 123,292 deliveries, and postpartum hemorrhage occurred in 5,931 (4.8%). Postpartum hemorrhage-control devices were used in 11.2% of cases (666 total, intrauterine balloon tamponade n=300, and vacuum-induced hemorrhage control n=366). For intrauterine balloon tamponade and vacuum-induced hemorrhage-control devices, quantitative blood loss (median and interquartile range) after device placement was similar at 194 (67-440) mL and 240 (113-528) mL (P=.40), respectively, as was the rate of any packed RBC transfusion (59.7% vs 50.0%, P=.08), transfusion of 3 packed RBC units or more (27.0% vs 24.9%, P=.53), and device failure (7.7% vs 8.5%, P=.70). Placement of either device at a quantitative blood loss between 1,000 and 1,499 mL compared with 1,500 mL or more resulted in significantly lower rates of packed RBC transfusion (39.1% vs 70.3%, P<.001), transfusion of 3 or more packed RBC units (13.7 vs 38.1%, P<.001), and device failure (3.4% vs 12.9%, P<.001). CONCLUSION: Transfusion and blood loss after device placement were similar with both hemorrhage-control devices. Earlier hemorrhage-control device placement reduced device failure and the need for transfusion.

Performance Characteristics of Sepsis Screening Tools During Antepartum and Postpartum Admissions.

OBJECTIVE: To evaluate the performance characteristics of existing screening tools for the prediction of sepsis during antepartum and postpartum readmissions. METHODS: This was a case-control study using electronic health record data obtained between 2016 and 2021 from 67 hospitals for antepartum sepsis admissions and 71 hospitals for postpartum readmissions up to 42 days. Patients in the sepsis case group were matched in a 1:4 ratio to a comparison cohort of patients without sepsis admitted antepartum or postpartum. The following screening criteria were evaluated: the CMQCC (California Maternal Quality Care Collaborative) initial sepsis screen, the non-pregnancy-adjusted SIRS (Systemic Inflammatory Response Syndrome), the MEWC (Maternal Early Warning Criteria), UKOSS (United Kingdom Obstetric Surveillance System) obstetric SIRS, and the MEWT (Maternal Early Warning Trigger Tool). Time periods were divided into early pregnancy (less than 20 weeks of gestation), more than 20 weeks of gestation, early postpartum (less than 3 days postpartum), and late postpartum through 42 days. False-positive screening rates, C-statistics, sensitivity, and specificity were reported for each overall screening tool and each individual criterion. RESULTS: We identified 525 patients with sepsis during an antepartum hospitalization and 728 patients with sepsis during a postpartum readmission. For early pregnancy and more than 3 days postpartum, non-pregnancy-adjusted SIRS had the highest C-statistics (0.78 and 0.83, respectively). For more than 20 weeks of gestation and less than 3 days postpartum, the pregnancy-adjusted sepsis screening tools (CMQCC and UKOSS) had the highest C-statistics (0.87-0.94). The MEWC maintained the highest sensitivity rates during all time periods (81.9-94.4%) but also had the highest false-positive rates (30.4-63.9%). The pregnancy-adjusted sepsis screening tools (CMQCC, UKOSS) had the lowest false-positive rates in all time periods (3.9-10.1%). All tools had the lowest C-statistics in the periods of less than 20 weeks of gestation and more than 3 days postpartum. CONCLUSION: For admissions early in pregnancy and more than 3 days postpartum, non-pregnancy-adjusted sepsis screening tools performed better than pregnancy-adjusted tools. From 20 weeks of gestation through up to 3 days postpartum, using a pregnancy-adjusted sepsis screening tool increased sensitivity and minimized false-positive rates. The overall false-positive rate remained high.

Performance Characteristics of Sepsis Screening Tools During Delivery Admissions.

OBJECTIVE: To evaluate the screening performance characteristics of existing tools for the diagnosis of sepsis during delivery admissions. METHODS: This was a case-control study using electronic health record data, including vital signs and laboratory results, for all delivery admissions of patients with sepsis from 59 nationally distributed hospitals. Patients with sepsis were matched by gestational age at delivery in a 1:4 ratio with patients without sepsis to create a comparison group. Patients with chorioamnionitis and sepsis were compared with a complete cohort of patients with chorioamnionitis without sepsis. Multiple screening criteria for sepsis were evaluated: the CMQCC (California Maternal Quality Care Collaborative), SIRS (Systemic Inflammatory Response Syndrome), the MEWC (the Maternal Early Warning Criteria), UKOSS (United Kingdom Obstetric Surveillance System), and the MEWT (Maternal Early Warning Trigger Tool). Sensitivity, false-positive rates, and C-statistics were reported for each screening tool. Analyses were stratified into cohort 1, which excluded patients with chorioamnionitis-endometritis, and cohort 2, which included those patients. RESULTS: Delivery admissions at 59 hospitals were extracted for patients with sepsis. Cohort 1 comprised 647 patients with sepsis, including 228 with end-organ injury, matched with a control group of 2,588 patients without sepsis. Cohort 2 comprised 14,591 patients with chorioamnionitis-endometritis, of whom 1,049 had sepsis and 238 had end-organ injury. In cohort 1, the CMQCC and the UKOSS pregnancy-adjusted criteria had the lowest false-positive rates (6.9% and 9.6%, respectively) and the highest C-statistics (0.92 and 0.91, respectively). Although other screening criteria, such as SIRS and the MEWC, had similar sensitivities, it was at the cost of much higher false-positive rates (21.3% and 38.3%, respectively). In cohort 2, including all patients with chorioamnionitis-endometritis, the highest C-statistics were again for the CMQCC (0.67) and UKOSS (0.64). All screening tools had high false-positive rates, but the false-positive rates for the CMQCC and UKOSS were substantially lower than those for SIRS and the MEWC. CONCLUSION: During delivery admissions, the CMQCC and UKOSS pregnancy-adjusted screening criteria have the lowest false-positive results while maintaining greater than 90% sensitivity rates. Performance of all screening tools was degraded in the setting of chorioamnionitis-endometritis.

A Systemwide Postpartum Inpatient Maternal Mental Health Education and Screening Program.

OBJECTIVE: To expand a hospital system's maternal mental health program to standardize screening for perinatal mood and anxiety disorders. DESIGN: Quality improvement initiative using a continuous Plan-Do-Study-Act (PDSA) cycle. SETTING/LOCAL PROBLEM: In a hospital system consisting of 66 maternity care centers across the United States, there was significant variation in maternal mental health screening, referral, and education practices. The COVID-19 pandemic and increasing rates of severe maternal morbidity further elevated system-level concern about the quality of maternal mental health care being provided. PARTICIPANTS: Perinatal nurses. METHODS: An "all-or-none" bundle methodology was used to measure adherence to a system standard for maternal mental health screening, referral, and education. INTERVENTIONS: A toolkit was designed internally to support streamlined implementation and ensure standardization for screening, referral, and education. This comprehensive toolkit includes screening forms, a referral algorithm, staff education, patient education literature, and a community resource list template. Training on how to use the toolkit was provided to nurses, chaplains, and social workers. RESULTS: The initial system bundle adherence rate was 76% (2017) in the first year of the program. The following year, the bundle adherence rate increased to 97% (2018). Despite the disruption caused by the COVID-19 pandemic, this mental health initiative has maintained an overall adherence rate of 92% (2020-2022). CONCLUSION: This nurse-led quality improvement initiative has been successfully implemented across a geographically and demographically diverse hospital system. The initial and sustained high rates of adherence with the system standard for screening, referral, and education illustrate perinatal nurses' commitment to the delivery of high-quality maternal mental health care in the acute care setting.