Trends and outcomes for deliveries with hypertensive disorders of pregnancy from 2000 to 2018: A repeated cross-sectional study.

OBJECTIVE: To analyse trends, risk factors, and outcomes related to hypertensive disorders of pregnancy (HDP). DESIGN: Repeated cross-sectional. SETTING: US delivery hospitalisations. POPULATION: Delivery hospitalisations in the 2000-2018 National Inpatient Sample. METHODS: US hospital delivery hospitalisations with HDP were analysed. Several trends were analysed: (i) the proportion of deliveries by year with HDP, (ii) the proportion of deliveries with HDP risk factors and (iii) adverse outcomes associated with HDP including maternal stroke, acute renal failure and acute liver injury. Risk ratios were determined using regression models with HDP as the exposure of interest. MAIN OUTCOME MEASURES: Prevalence of HDP, risk factors for HDP and associated adverse outcomes. RESULTS: Of 73.1 million delivery hospitalisations, 7.7% had an associated diagnosis of HDP. Over the study period, HDP doubled from 6.0% of deliveries in 2000 to 12.0% in 2018. The proportion of deliveries with risk factors for HDP increased from 9.6% in 2000 to 24.6% in 2018. In adjusted models, HDP were associated with increased stroke (aRR [adjusted risk ratio] 15.9, 95% CI 14.8-17.1), acute renal failure (aRR 13.8, 95% CI 13.5-14.2) and acute liver injury (aRR 1.2, 95% CI 1.2-1.3). Among deliveries with HDP, acute renal failure and acute liver injury increased; in comparison, stroke decreased. CONCLUSION: Hypertensive disorders of pregnancy increased in the setting of risk factors for HDP becoming more common, whereas stroke decreased. TWEETABLE ABSTRACT: While hypertensive disorders of pregnancy increased from 2000 to 2018, stroke appears to be decreasing.

Safety of tocilizumab in COVID-19 pregnant women and their newborn: A retrospective study.

WHAT IS KNOWN AND OBJECTIVE: Tocilizumab is an IL-6 receptor inhibitor agent which has been proposed as a candidate to stop the inflammatory phase of infection by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). However, safety data of tocilizumab in pregnant women and their newborn are scarce. We aimed to describe maternal and neonatal safety outcomes associated with tocilizumab treatment in pregnant women with severe COVID-19. METHODS: This is a retrospective study of severe COVID-19 pregnant women, treated with tocilizumab in two Spanish hospitals between 1 March and 31 April 2020. Demographics, medical history, clinical and radiologic findings, treatment information and laboratory data of mothers and their newborns were collected from electronic medical records. RESULTS AND DISCUSSION: A total of 12 pregnant women were identified to have received tocilizumab during pregnancy in the two hospitals. Median gestational age at admission was 27.7 weeks (interquartile range, 18.0-36.4). Most of them received lopinavir/ritonavir, azithromycin and hydroxychloroquine, two patients received corticosteroids and one received interferon beta 1B. All 12 pregnancies resulted in live births. Somatometric values were normal for all newborns, and evolution at 14 and 28 days was favourable for all of them. Hepatotoxicity was observed in 2 patients, which improved or resolved at discharge. Cytomegalovirus reactivation was detected in another patient who had also received corticosteroids for 15 days, causing a congenital infection in her newborn. Both hepatotoxicity and viral reactivation adverse events were classified as possibly related to tocilizumab administration according to Naranjo's causality algorithm. WHAT IS NEW AND CONCLUSIONS: It does not appear that tocilizumab has detrimental effects for the mother and newborn. Close monitoring of infections should be considered, especially if other immunosuppressive agents are used.

Reduction in racial disparities in severe maternal morbidity from hemorrhage in a large-scale quality improvement collaborative.

BACKGROUND: Eliminating persistent racial/ethnic disparities in maternal mortality and morbidity is a public health priority. National strategies to improve maternal outcomes are increasingly focused on quality improvement collaboratives. However, the effectiveness of quality collaboratives for reducing racial disparities in maternity care is understudied. OBJECTIVE: To evaluate the impact of a hemorrhage quality-improvement collaborative on racial disparities in severe maternal morbidity from hemorrhage. STUDY DESIGN: We conducted a cross-sectional study from 2011 to 2016 among 99 hospitals that participated in a hemorrhage quality improvement collaborative in California. The focus of the quality collaborative was to implement the national maternal hemorrhage safety bundle consisting of 17 evidence-based recommendations for practice and care processes known to improve outcomes. This analysis included 54,311 women from the baseline period (January 2011 through December 2014) and 19,165 women from the postintervention period (October 2015 through December 2016) with a diagnosis of obstetric hemorrhage during delivery hospitalization. We examined whether racial/ethnic-specific severe maternal morbidity rates in these women with obstetric hemorrhage were reduced from the baseline to the postintervention period. In addition, we conducted Poisson Generalized Estimating Equation models to estimate relative risks and 95% confidence intervals for severe maternal morbidity comparing each racial/ethnic group with white. RESULTS: During the baseline period, the rate of severe maternal morbidity among women with hemorrhage was 22.1% (12,002/54,311) with the greatest rate observed among black women (28.6%, 973/3404), and the lowest among white women (19.8%, 3124/15,775). The overall rate fell to 18.5% (3553/19,165) in the postintervention period. Both black and white mothers benefited from the intervention, but the benefit among black women exceeded that of white women (9.0% vs 2.1% absolute rate reduction). The baseline risk of severe maternal morbidity was 1.34 times greater among black mothers compared with white mothers (relative risk, 1.34; 95% confidence interval, 1.27-1.42), and it was reduced to 1.22 (1.05-1.40) in the postintervention period. Sociodemographic and clinical factors explained a part of the black-white differences. After controlling for these factors, the black-white relative risk was 1.22 (95% confidence interval, 1.15-1.30) at baseline and narrowed to 1.07 (1.92-1.24) in the postintervention period. Results were similar when excluding severe maternal morbidity cases with transfusion alone. After accounting for maternal risk factors, the black-white relative risk for severe maternal morbidity excluding transfusion alone was reduced from a baseline of 1.33 (95% confidence interval, 1.16-1.52) to 0.99 (0.76-1.29) in the postintervention period. The most important clinical risk factor for disparate black rates for both severe maternal morbidity and severe maternal morbidity excluding transfusion alone was cesarean delivery, potentially providing another opportunity for quality improvement. CONCLUSION: A large-scale quality improvement collaborative reduced rates of severe maternal morbidity due to hemorrhage in all races and reduced the performance gap between black and white women. Improving access to highly effective treatments has the potential to decrease disparities for care-sensitive acute hospital-focused morbidities.

Putting the "M" back in maternal-fetal medicine: A 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United States.

The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014, with a mortality rate of 18.0 per 100,000, higher than in many other developed countries. In 2012, the first "Putting the 'M' back in Maternal-Fetal Medicine" session was held at the Society for Maternal-Fetal Medicine's (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the "M in MFM" meeting identified the following urgent needs: (i) to enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) to improve the medical care and management of pregnant women across the country; and (iii) to address critical research gaps in maternal medicine. Since that first meeting, a broad collaborative effort has made a number of major steps forward, including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 M in MFM meeting served as a "report card" looking back at progress made but also looking forward to what needs to be done over the next 5 years, given that too many mothers still experience preventable harm and adverse outcomes.

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.

Challenges in Conducting Therapeutic Trials in Pregnancy: Emphasizing Recent Lessons Learned.

Pregnant people have traditionally been excluded from therapeutic research by restrictions intended for fetal protection. Despite a movement toward inclusion, concerns for the feasibility and safety of including pregnant people in studies continue to limit this research. This article reviews the history of research guidelines in pregnancy and illustrates ongoing challenges, as seen in the development of vaccines and therapies during the coronavirus disease 2019 pandemic and investigation of statins for preeclampsia prevention. It explores new approaches that may be used to improve therapeutic research in pregnancy. A major cultural shift is needed to balance potential maternal and/or fetal risks with potential benefits from participation in research, as well as harm from withholding treatment or providing one that is not evidence-based. Finally, it is important to honor maternal autonomy in decision-making regarding participation in clinical trials.

A multicenter interdisciplinary survey of practices and opinions regarding oral intake during labor.

INTRODUCTION: Different society guidelines diverge regarding oral intake in labor. Our goal was to assess practices and opinions in Israeli labor and delivery units, comparing different disciplines. METHODS: An anonymous Google Forms survey was sent to anesthesiologists, obstetricians and midwives in all Israeli labor and delivery units. RESULTS: Responses were collected from all 27 labor and delivery units contacted, with a total of 501 respondents comprising 161 anesthesiologists, 102 obstetricians and 238 midwives. Forty-eight per cent stated there were no institutional guidelines for oral intake. The most common oral intake permitted was light food (60%). Midwives were significantly more likely than anesthesiologists and obstetricians to consider that women who are both low risk for cesarean delivery (P <0.00001) and high risk for cesarean delivery (P=0.001) should eat. Epidural analgesia did not impact recommendations regarding oral intake. The most common reasons for restricting oral intake were obstetric. Sixty-two per cent identified aspiration as the main risk associated with eating during labor, but 19% of midwives compared with 4% of anesthesiologists and obstetricians stated there were no risks (P <0.00001). The annual delivery volume of the unit did not impact staff practices. CONCLUSIONS: There was a discrepancy between opinions and practices across all disciplines. Permissive practices identified in this survey should be addressed to find the safe middle ground between restrictive and permissive policies for low- and high-risk women.

Measurement of hemorrhage-related severe maternal morbidity with billing versus electronic medical record data.

OBJECTIVE: Measurement of obstetric hemorrhage-related morbidity is important for quality assurance purposes but presents logistical challenges in large populations. Billing codes are typically used to track severe maternal morbidity but may be of suboptimal validity. The objective of this study was to evaluate the validity of billing code diagnoses for hemorrhage-related morbidity compared to data obtained from the electronic medical record. STUDY DESIGN: Deliveries occurring between July 2014 and July 2017 from three hospitals within a single system were analyzed. Three outcomes related to obstetric hemorrhage that are part of the Centers for Disease Control and Prevention definition of severe maternal morbidity (SMM) were evaluated: (i) transfusion, (ii) disseminated intravascular coagulation (DIC), and (iii) acute renal failure (ARF). ICD-9-CM and ICD-10-CM for these conditions were ascertained and compared to blood bank records and laboratory values. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) with 95% confidence intervals (CI) were calculated. Ancillary analyses were performed comparing codes and outcomes between hospitals and comparing ICD-9-CM to ICD-10-CM codes. Comparisons of categorical variables were performed with the chi-squared test. T-tests were used to compare continuous outcomes. RESULTS: 35,518 deliveries were analyzed. 786 women underwent transfusion, 168 had serum creatinine ≥1.2 mg/dL, and 99, 40, and 16 had fibrinogen ≤200, ≤150, and ≤100 mg/dL, respectively. Transfusion codes were 65% sensitive (95% CI 62-69%) with a 91% PPV (89-94%) for blood bank records of transfusion. DIC codes were 22% sensitive (95% CI 15-32%) for a fibrinogen cutoff of ≤200 mg/dL with 15% PPV (95% CI 10-22%). Sensitivity for ARF was 33% (95% CI 26-41%) for a creatinine of 1.2 mg/dL with a PPV of 63% (95% CI 52-73%). Sensitivity of ICD-9-CM for transfusion was significantly higher than ICD-10-CM (81%, 95% CI 76-86% versus 56%, 95% CI 51-60%, p < .01). Evaluating sensitivity of codes by individual hospitals, sensitivity of diagnosis codes for transfusion varied significantly (Hospital A 47%, 95% CI 36-58% versus Hospital B 63%, 95% CI 58-67% versus Hospital C 80%, 95% CI 74-86%, p < .01). CONCLUSION: Use of administrative billing codes for postpartum hemorrhage complications may be appropriate for measuring trends related to disease burden and resource utilization, particularly in the case of transfusion, but may be suboptimal for measuring clinical outcomes within and between hospitals.

Cardiovascular Diseases in Pregnancy - A Brief Overview.

Even though, there have been many advances in maternal medical care and fertility treatments, the presence of cardiovascular disease has a significant impact on pregnancy. In pregnant women, several heart conditions, such as valvular heart disease, chronic hypertension, congenital heart defects and non-ischemic cardiomyopathies are linked to increased risk of fetal as well as maternal morbidity and mortality. To date, the management of the co-existing conditions of pregnancy and heart disease has been challenging. Therefore, in-depth information may be beneficial to tackle a difficult case scenario. Towards this end, this paper provides an overview of the recent updated knowledge of pregnancy-related cardiovascular diseases in women.

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.

Longitudinal Risk Adjustment for Maternal End-Organ Injury and Death.

OBJECTIVE: To determine whether adjusting for healthcare utilization and comorbidity diagnosed in the year before delivery improves the prediction of adverse maternal outcomes. METHODS: The Truven Health MarketScan database was used to determine whether healthcare utilization and comorbidity diagnosed in the year before pregnancy improved prediction of acute organ injury or death during the delivery hospitalization through 30 days postpartum in this retrospective cohort study. In an initial model, we analyzed the risk for adverse outcomes controlling for underlying comorbidity, obesity, and demographic risk factors present during pregnancy. Subsequent models included diagnoses from the year before pregnancy as well as whether patients had emergency department encounters, inpatient hospitalizations, or received medications from a pharmacy. We compared risk estimates and whether prediction of acute organ injury or death improved with data from the year before pregnancy. Unadjusted and adjusted log-linear regression models were performed to demonstrate the association between exposures and outcomes with unadjusted (RR) and adjusted risk ratios (aRR) with 95% CIs as measures of effects. Logistic regression was performed to calculate the c-statistic of the adjusted models. Separate analyses were performed for patients with Medicaid and commercial insurance. An analysis of Medicaid patients by maternal race and ethnicity was performed to determine if diagnoses and utilization before pregnancy accounted for maternal disparities. RESULTS: A total of 740,002 patients were analyzed in this study. In unadjusted analyses of patients with commercial insurance, ≥2 compared to 0 emergency department encounters (RR = 1.82, 95% CI = 1.61, 2.07), ≥2 compared to 0 inpatient hospitalizations (RR = 4.43, 95% CI = 3.20, 6.13), and receipt of medications from ≥5 prescription groups compared to no prescriptions (RR = 1.97, 95% CI = 1.74, 2.24) were all associated with increased risk for acute organ injury or death. Higher underlying comorbidity and obesity were also associated with increased risk. These risks were attenuated in adjusted analyses but retained significance. Risk estimates were similar for patients with Medicaid insurance with the exception of receipt of medications from ≥5 prescription groups which was non-significant in adjusted analyses (aRR = 1.12, 95% CI = 0.90, 1.40). C-statistics from logistic regression models were similar for models with and without pre-pregnancy data. When race was added to the adjusted models, risk among black women in the adjusted models did not differ significantly from the unadjusted estimate. CONCLUSION: ED encounters and inpatient admissions the year before pregnancy were associated with increased risk of adverse maternal outcomes. However, adding these risk factors to adjusted models did not meaningfully improve the amount of variance accounted for. Further research is indicated to determine to what degree longitudinal care quality is associated with maternal risk.

Management of breast cancer diagnosed during pregnancy: global perspectives.

INTRODUCTION: Pregnancy-associated breast cancer (PABC) encompasses breast cancer diagnosed during pregnancy (BCP) or postpartum (PPBC). BCP is especially challenging with concerns regarding maternal and fetal safety synchronously. This review provides a comprehensive global view to optimize care of this unique entity. Areas covered Published literature and practices across the globe including real world published data from the first Indian registry are thoroughly reviewed to derive inferences. Diagnostic delays are common with resultant upstaging and inferior outcomes. Sonography-mammography and a biopsy with immunohistochemistry for estrogen, progesterone and HER-2neu receptors is mandatory. Multidisciplinary specialist teams are critical for trimester dependent management. Stage-wise surgical and systemic treatment remains largely similar to that of the nonpregnant women. Anthracyclines- and taxane-based chemotherapy is found to be safe after the 1st trimester. Frequent fetal and maternal monitoring is required to minimize complications. Chemotherapy should stop three weeks prior to the delivery to prevent peripartum infection/bleeding. Anti- Her-2 targeted therapy, endocrine therapy and radiation therapy are administered post-delivery. Iatrogenic premature delivery leads to poor neurocognition and should be avoided. Expert opinion Stage-wise outcomes are similar to that of non-pregnant patients with breast cancer, and underscores the importance of early detection especially in low- and middle-income countries. Global collaborations are warranted. AREAS COVERED: Published literature and practices across the globe including real world published data from the first Indian registry are thoroughly reviewed to derive inferences. Diagnostic delays are common with resultant upstaging and inferior outcomes. Sonography-mammography and a biopsy with immunohistochemistry for estrogen, progesterone and HER-2neu receptors is mandatory. Multidisciplinary specialist teams are critical for trimester dependent management. Stage-wise surgical and systemic treatment remains largely similar to that of the nonpregnant women. Anthracyclines- and taxane-based chemotherapy is found to be safe after the 1st trimester. Frequent fetal and maternal monitoring is required to minimize complications. Chemotherapy should stop three weeks prior to the delivery to prevent peripartum infection/bleeding. Anti- Her-2 targeted therapy, endocrine therapy and radiation therapy are administered post-delivery. Iatrogenic premature delivery leads to poor neurocognition and should be avoided. EXPERT OPINION: Stage-wise outcomes are similar to that of non-pregnant patients with breast cancer, and underscores the importance of early detection especially in low- and middle-income countries. Global collaborations are warranted.

Postpartum hemorrhage and risk for postpartum readmission.

Objective: This study had two objectives: (i) to evaluate risk factors for postpartum readmission for a primary diagnosis of postpartum hemorrhage (PPH) among all women, and (ii) to determine risk for postpartum readmission specifically among women with PPH during their delivery hospitalization.Methods: The Healthcare Cost and Utilization Project's Nationwide Readmissions Database for 2010 to 2014 was used to evaluate risk for postpartum readmission for PPH within 60 days of discharge from a delivery hospitalization. Obstetric, medical, demographic, and hospital factors including PPH during the index delivery were analyzed. Sixty-day postpartum readmission for PPH was the primary outcome. Both unadjusted and adjusted analyses were performed. In adjusted models, the risk was characterized as adjusted risk ratios (aRR) with 95% confidence intervals (CI). As a secondary outcome to further characterize how PPH at delivery was associated with readmission likelihood, the risk for all-cause readmission was evaluated among women with this diagnosis during their delivery.Results: Of the 15,701,150 delivery hospitalizations, 10,618 women were readmitted postpartum for a primary indication of postpartum hemorrhage. Eighty-two percent of readmissions occurred ≤20 days after discharge. In the adjusted model for readmission for PPH, PPH during the delivery hospitalization was associated with aRR of 5.26 (95% CI 4.94, 5.59) for hemorrhage alone, aRR of 14.28 (95% CI 13.06, 15.60) for hemorrhage requiring transfusion, and aRR of 12.40 for PPH with disseminated intravascular coagulation (DIC) requiring transfusion (95% CI 9.56-16.08) compared to no PPH. For the secondary analysis evaluating all-cause readmission, PPH during delivery was associated with aRR of 1.47 for PPH alone (95% CI 1.44-1.51), aRR of 2.43 for PPH requiring transfusion (95% CI 2.34-2.52), and aRR of 2.77 for PPH with DIC requiring transfusion (95% CI 2.54-3.03) compared to no PPH.Conclusion: PPH at delivery is a significant risk factor for subsequent readmission both for PPH and for all causes. For women who undergo large hemorrhage during delivery, shorter interval postpartum follow-up may be indicated.

Risk for postpartum readmissions and associated complications based on maternal age.

PURPOSE: To evaluate risk for postpartum readmissions and associated severe morbidity by maternal age. MATERIALS AND METHODS: This retrospective cohort study used the Nationwide Readmissions Database to analyze 60-day all-cause postpartum readmission risk from 2010 to 2014. Risk for severe maternal morbidity (SMM) during readmission was ascertained using criteria from the Centers for Disease Control and Prevention. The primary exposure of interest was maternal age. Outcomes included time to readmission, risk of readmission, and risk for SMM during readmission. Multivariable log linear analyses adjusting for patient, obstetric, and hospital factors were conducted to assess readmission and SMM risk with adjusted risk ratios (aRRs) with 95% confidence intervals (CIs) as measures of effect. RESULTS: Between 2010 and 2014, we identified 15.7 million deliveries, 15% of which were to women aged 35 or older. The 60-day all-cause readmission rate was 1.7%. Of these, 13% were complicated by SMM. Age-stratification revealed that women 35 and older were at increased risk for readmission and increased risk for SMM. The majority of readmissions occurred within the first 20 days regardless of age; although, women 35 and older were more likely to be admitted within the first 10 days of discharge. Patients ages 35-39, 40-44, and >44 years had 9% (95% CI 7-10%), 37% (95% CI 34-39%), and 66% (95% CI 55-79%) significantly higher rates of postpartum readmission when compared to women age 25-29. Women 35-39, 40-44, and >44 years of age had a 15% (95% CI 10-21%), 26% (95% CI 18-34%), and 56% (95% CI 25-94%) higher risk of a readmission with SMM than women 25-29. CONCLUSIONS: AMA women are at higher risk for both postpartum readmission and severe morbidity during readmission. Women older than 35 years represent the group most likely to experience complications requiring readmission, with the highest risk age 40 and older.

Obstetric outcomes among women with a liver transplant.

BACKGROUND: Women with liver transplants may be at increased risk for adverse outcomes. OBJECTIVE: The objectives of this study were to evaluate trends and provide recent data on outcomes for women with a liver transplant. STUDY DESIGN: The National (Nationwide) Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project from 1998 to 2014 was used for this repeated cross-sectional analysis. Women aged between 15 and 54 years, with a history of liver transplant who underwent delivery, antepartum, or postpartum hospitalizations were identified. Temporal trends in deliveries of women with liver transplants were analyzed. The risk for severe maternal morbidity (SMM) excluding transfusion based on criteria from the Centers for Disease Control and Prevention (CDC), as well as for individual outcomes including hypertensive diseases of pregnancy, postpartum hemorrhage, placental abruption, liver rejection, cesarean delivery, preterm delivery, and coagulopathy during delivery hospitalizations were analyzed. Risks of SMM during antepartum and postpartum hospitalizations were also analyzed. An adjusted log-linear regression model for SMM during delivery hospitalizations including demographic factors, hospital characteristics, and underlying comorbidity was performed. The chi-squared or Fisher's exact test was used for comparisons. Temporal trends were analyzed with the Cochran-Armitage trend test. Population weights were applied to create national estimates. RESULTS: From 1998 to 2014, an estimated 1165 births occurred by women with a liver transplant. The number of births occurring by women with liver transplants increased over the study period from 1.0 per 100,000 in 1998-2000 to 2.8 per 100,000 in 2012-2014 (p < .01). The risk for CDC SMM excluding transfusion was significantly higher during delivery hospitalizations among women with compared to without liver transplant (8.0 versus 0.5%, p < .01, unadjusted risk ratio 15.4, 95% CI 12.7-18.6). Women with liver transplant were also at significantly higher risk for abruption (2.5 versus 1.0%, p = .03), hypertensive diseases of pregnancy (27.8 versus 6.9%, p < .01), postpartum hemorrhage (8.0 versus 2.8%, p = .01), cesarean delivery (51.7 versus 29.5%, p < .01), preterm delivery (27.5 versus 7.0%, p < .01), and coagulopathy (3.1 versus 0.3%, p < .01). A diagnosis of liver rejection was present during 4.1% of delivery hospitalizations for women with liver transplant. In the adjusted analysis for severe morbidity excluding transfusion risk was retained with liver transplant associated with increased likelihood of this adverse outcome (aRR 8.49, 95% CI 5.59-12.87). Women with liver transplants were at significantly higher likelihood of undergoing antepartum and postpartum admissions, and of experiencing SMM during these hospitalizations. CONCLUSION: In this analysis of antepartum, delivery, and postpartum hospitalizations, women with liver transplant were at significantly higher risk for both SMM during all hospitalizations and for a range of adverse outcomes including placental abruption, hypertensive diseases of pregnancy, postpartum hemorrhage, cesarean delivery, and coagulopathy delivery during delivery hospitalizations. While deliveries to women with liver transplant were rare, these births became more frequent over the study period.

Fetal Cardiac Interventions-Are They Safe for the Mothers?

The aim of fetal cardiac interventions (FCI), as other prenatal therapeutic procedures, is to bring benefit to the fetus. However, the safety of the mother is of utmost importance. The objective of our study was to evaluate the impact of FCI on maternal condition, course of pregnancy, and delivery. 113 mothers underwent intrauterine treatment of their fetuses with critical heart defects. 128 percutaneous ultrasound-guided FCI were performed and analyzed. The patients were divided into four groups according to the type of FCI: balloon aortic valvuloplasty (fBAV), balloon pulmonary valvuloplasty (fBPV), interatrial stent placement (IAS), and balloon atrioseptoplasty (BAS). Various factors: maternal parameters, perioperative data, and pregnancy complications, were analyzed. There was only one major complication-procedure-related placental abruption (without need for blood products transfusion). There were no cases of: procedure-related preterm prelabor rupture of membranes (pPROM), chorioamnionitis, wound infection, and anesthesia associated complications. Tocolysis was only necessary only in two cases, and it was effective in both. None of the patients required intensive care unit admission. The procedure was effective in treating polyhydramnios associated with fetal heart failure in six out of nine cases. Deliveries occurred at term in 89%, 54% were vaginal. The results showed that FCI had a negligible impact on a further course of pregnancy and delivery.

Clinical Implications of Maternal Disparities Administrative Data Research.

Administrative data research on maternal racial disparities supports 2 broad clinical inferences. First, failure to rescue in terms of both death and severe maternal morbidity likely accounts for a significant proportion of maternal disparities. Second, risk for adverse outcomes by race is generally differential with risk for cardiovascular complications particularly high for non-Hispanic black women. These differentials suggest that underlying health conditions may represent an important contributor to overall disparities, and optimal longitudinal care utilization with nonobstetric specialists is required to mitigate risk.

Leveraging resources for obstetric venous thromboembolism prevention in a state safety collaborative.

In recent years, state obstetric quality and maternal safety initiatives have led efforts to reduce maternal risk and improve maternal safety. A priority of many of these collaboratives has been to disseminate and implement safety bundles focusing on leading causes of maternal mortality including venous thromboembolism. In 2013, the Safe Motherhood Initiative (SMI), a quality improvement effort led by ACOG District II in New York State, began developing a VTE bundle reviewed available clinical evidence, practice guidelines, and protocols and assessed how hospitals with varying resources could implement standardized approaches to obstetric thromboembolism prophylaxis. This bundle was subsequently released for implementation in New York State's hospitals with support from SMI. The purpose of this review is to characterize, from the perspective of a state safety leadership collaborative, the resources that were most critical in assisting individual hospitals in (i) determining which VTE prophylaxis strategies would be adopted, and (ii) operationalizing implementation.

Optimizing obstetric venous thromboembolism protocol adherence: The experience of a hospital system.

The purpose of this review is to explore the role of hospital systems in reliably providing high quality obstetric venous thromboembolism (VTE) prophylaxis focusing on the example of the Kaiser Permanente Southern California hospital system. While providers ultimately administer thromboprophylaxis on a patient-by-patient basis, hospital-level protocols, practices, and resources may be the most important determinants of whether a patient receives appropriate care. In comparison to the complex maternal and fetal emergencies that obstetricians are routinely called on to manage, VTE prophylaxis can often be simplified and integrated into the workflow, making decision-making time efficient and straightforward for the provider. Not having protocols (i.e. the provider being on their own) is associated with desired management occurring in only 40% of cases. Enhanced VTE protocols with complementary strategies to encourage use and identification of oversights addressed in real time can result in appropriate care in >90% of cases.