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.

Fragmentation of postpartum readmissions in the United States.

BACKGROUND: Fragmentation of care, wherein a patient is readmitted to a hospital different from the initial point of care, has been shown to be associated with worse patient outcomes in other medical specialties. However, postpartum fragmentation of care has not been well characterized in obstetrics. OBJECTIVE: To characterize risk for and outcomes associated with fragmentation of postpartum readmissions wherein the readmitting hospital is different than the delivery hospital. METHODS: The 2010 to 2014 Nationwide Readmissions Database was used for this retrospective cohort study. Postpartum readmissions within 60 days of delivery hospitalization discharge for women aged 15-54 years were identified. The primary outcome, fragmentation, was defined as readmission to a different hospital than the delivery hospital. Hospital, demographic, medical, and obstetric factors associated with fragmented readmission were analyzed. Adjusted log-linear models were performed to analyze risk for readmission with adjusted risk ratios and 95% confidence intervals as the measures of effect. The associations between fragmentation and secondary outcomes including (1) length of stay >90th percentile, (2) hospitalization costs >90th percentile, and (3) severe maternal morbidity were determined. Whether specific indications for readmission such as hypertensive diseases of pregnancy, wound complications, and other conditions were associated with higher or lower risk for fragmentation was analyzed. RESULTS: From 2010 to 2014, 141,276 60-day postpartum readmissions were identified, of which 15% of readmissions (n = 21,789) occurred at a hospital different from where the delivery occurred. Evaluating individual readmission indications, fragmentation was less likely for hypertension (11.1%), wound complications (10.7%), and uterine infections (11.0%), and more likely for heart failure (28.6%), thromboembolism (28.4%), and upper respiratory infections (33.9%) (P < .01 for all). In the adjusted analysis, factors associated with fragmentation included public insurance compared to private insurance (Medicare: adjusted risk ratio, 1.68; 95% confidence interval, 1.52, 1.86; Medicaid: adjusted risk ratio, 1.28; 95% confidence interval, 1.24, 1.32). Fragmentation was associated with increased risk for severe maternal morbidity during readmissions in both unadjusted (relative risk, 1.84; 95% confidence interval, 1.79, 1.89) and adjusted (adjusted risk ratio, 1.81; 95% confidence interval, 1.76, 1.86) analyses. In adjusted analyses, fragmentation was also associated with increased risk for length of stay >90th percentile (relative risk, 1.48; 95% confidence interval, 1.42-1.54) and hospitalization costs >90th percentile (adjusted risk ratio, 1.74; 95% confidence interval, 1.67, 1.81). CONCLUSION: This study of nationwide estimates of postpartum fragmentation found discontinuity of postpartum care was associated with increased risk for severe morbidity, high costs, and long length of stay. Reduction of fragmentation may represent an important goal in overall efforts to improve postpartum care.

Diagnostic Errors in Obstetric Morbidity and Mortality: Methods for and Challenges in Seeking Diagnostic Excellence.

Pregnancy-related morbidity and mortality remain high across the United States, with the majority of deaths being deemed preventable. Misdiagnosis and delay in diagnosis are thought to be significant contributors to preventable harm. These diagnostic errors in obstetrics are understudied. Presented here are five selected research methods to ascertain the rates of and harm associated with diagnostic errors and the pros and cons of each. These methodologies include clinicopathologic autopsy studies, retrospective chart reviews based on clinical criteria, obstetric simulations, pregnancy-related harm case reviews, and malpractice and administrative claim database research. We then present a framework for a future study of diagnostic errors and the pursuit of diagnostic excellence in obstetrics: (1) defining and capturing diagnostic errors, (2) targeting bias in diagnostic processes, (3) implementing and monitoring safety bundles, (4) leveraging electronic health record triggers for case reviews, (5) improving diagnostic skills via simulation training, and (6) publishing error rates and reduction strategies. Evaluation of the effectiveness of this framework to ascertain diagnostic error rates, as well as its impact on patient outcomes, is required.

Acquired Hemophilia A: A Rare, Acquired Coagulopathy in the Postpartum Setting.

Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity. Pregnancy-associated acquired hemophilia A (AHA) caused by autoantibodies against factor VIII can present with recurrent episodes of postpartum bleeding. Case 1 A 50-year-old G2P0112 presented with vaginal bleeding 22 days postcaesarean. She underwent dilation and curettage, hysterectomy, and interventional radiology (IR) embolization before AHA diagnosis. She was hospitalized for 32 days and received 23 units of blood product. She remains without relapse of AHA after 5 years. Case 2 A 48-year-old G3P1021 presented with vaginal bleeding 8 days postcaesarean. She underwent three surgeries and IR embolization before AHA diagnosis. She was hospitalized for 18 days and received 39 units of blood product. Prednisone and cyclophosphamide were continued after discharge. AHA is a rare cause of PPH. An isolated prolonged activated partial thromboplastin time (aPTT) should prompt further workup in postpartum patients with refractory bleeding. Rapid recognition of AHA can prevent significant morbidity related to hemorrhage, massive transfusion, and multiple surgeries.

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.

Advances in Management for Preterm Fetuses at Risk of Delivery.

Preterm birth accounts for only 11% of live births but contributes to up to 75% of neonatal mortality and more than half of long-term morbidity. Targeted interventions to reduce the most common causes of perinatal morbidity and mortality include intrapartum group B Streptococcus prophylaxis, magnesium sulfate for fetal neuroprotection, antenatal corticosteroids for fetal lung maturity, latency antibiotics for preterm premature rupture of membranes, and tocolysis to allow corticosteroid administration and transfer to a tertiary care center. This article reviews the evidence for interventions to improve outcomes for fetuses at risk for preterm delivery at different gestational ages.

Primed for a pandemic: Implementation of telehealth outpatient monitoring for women with mild COVID-19.

Close observation and rapid escalation of care is essential for obstetric patients with COVID-19. The pandemic forced widespread conversion of in-person to virtual care delivery and telehealth was primed to enable outpatient surveillance of infected patients. We describe the experience and lessons learned while designing and implementing a virtual telemonitoring COVID-19 clinic for obstetric patients. All patients with suspected for confirmed COVID-19 were referred and enrolled. Telehealth visits were conducted every 24 to 72 hours based on the severity of symptoms and care was escalated to in person when necessary. The outcome of the majority (96.1%) of telehealth visits was to continue outpatient management. With regard to escalation of care, 25 patients (26.6%) presented for in person evaluation and five patients (5.3%) required inpatient admission. A virtual telemonitoring clinic for obstetric patients with mild COVID-19 offers an effective surveillance strategy as it allows for close monitoring, direct connection to in person evaluation, minimization of patient and provider exposure, and scalability.

Testing biomimetic structures in bioinspired robots: how vertebrae control the stiffness of the body and the behavior of fish-like swimmers.

Our goal is to describe a specific case of a general process gaining traction amongst biologists: testing biological hypotheses with biomimetic structures that operate in bioinspired robots. As an example, we present MARMT (mobile autonomous robot for mechanical testing), a surface-swimmer that undulates a submerged biomimetic tail to power cruising and accelerations. Our goal was to test the hypothesis that stiffness of the body controls swimming behavior and that both stiffness and behavior can be altered by changes in the morphology of the vertebral column. To test this hypothesis, we built biomimetic vertebral columns (BVC) outfitted with variable numbers of rigid ring centra; as the number of centra increased the axial length of the intervertebral joints decreased. Each kind of BVC was tested in dynamic bending to measure the structure's apparent stiffness as the storage and loss moduli. In addition, each kind of BVC was used as the axial skeleton in a tail that propelled MARMT. We varied MARMT's tail-beat frequency, lateral amplitude of the tail, and swimming behavior. MARMT's locomotor performance was measured using an on-board accelerometer and external video. As the number of vertebrae in the BVC of fixed length increased, so, too, did the BVC's storage modulus, the BVC's loss modulus, MARMT's mean speed during cruising, and MARMT's peak acceleration during a startle response. These results support the hypothesis that stiffness of the body controls swimming behavior and that both stiffness and behavior can be altered by changes in the morphology of the vertebral column.