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While medications for anxiety and depression are commonly used in the United States, it is unclear to what degree they are continued during pregnancy. We used a large administrative database to determine whether psychiatric medications are continued during pregnancy and predictors of continued medication treatment. Of 2,672,656 women included in our analysis, 86,454 (3.1%) filled a pre-pregnancy prescription for an anxiolytic or antidepressant medication within 3 months of estimated conception. Of women who filled a pre-pregnancy prescription, 49.4%, 26.1%, and 20.1% filled subsequent prescriptions in the 1st, 2nd, and 3rd trimesters. Discontinuation rates ranged by pharmaceutical agent, from 16% for fluoxetine to 71% for alprazolam. White women and women over 25 were more likely to continue anxiolytic and antidepressant treatment during pregnancy. Because untreated and under-treated mental health conditions are linked to adverse maternal outcomes, high discontinuation rates may have important implications for maternal health. [ABSTRACT FROM AUTHOR]

Objective: To determine which antiepileptic drugs pregnant women receive by trimester. Methods: This retrospective cohort study using the IBM Watson Health MarketScan Research Databases evaluated which antiepileptic drugs pregnant women with epilepsy received by trimester. Women with aged 15-54 years with a history of seizure disorder who underwent a delivery hospitalization between 2008 and 2017 were included in the analysis. Descriptive statistics were performed. Results: Of 34,144 women with a seizure disorder diagnosis and a delivery hospitalization, 10,289 (30.1%) received an anti-epileptic medication during pregnancy of which more than half received lamotrigine or levetiracetam. Other antiepileptic medications used by >5% of the population during any one trimester in the study period included carbamazepine, clonazepam, and topiramate. In evaluating medication use in the 1st trimester versus the 2nd trimester, clonazepam use decreased 32.0% (95% CI 60.0%, 77.0%) from 5.6% to 3.8% of patients receiving antiepileptics from the 1st to the 2nd trimester, gabapentin deceased 22.1% (95% CI 0.68%, 0.90%) from 4.1% to 3.2%, and topiramate decreased 30.0% (95% CI 62.8%, 77.9%) from 7.2% to 5.1%. In comparison, levetiracetam increased from 22.5% to 33.3% between the 1st and 3rd trimester and lamotrigine 22.2% to 27.5% between the 1st and 3rd trimester, 48.3% and 24.0% increases respectively. Conclusion: Antiepileptic drugs with less favorable fetal risk profiles such as topiramate decreased by trimester while medications with more favorable fetal risk profiles such as lamotrigine and levetiracetam increased. These findings broadly support that there are opportunities to improve pre-conceptional counseling of women with epilepsy. [ABSTRACT FROM AUTHOR]

Objective: It is possible that in the setting of increasing patient comorbidity and obesity, risk for surgical injury and need for reoperation is increasing. It is also possible that with differential uptake of evidence-based recommendations and increasing prevalence of risk factors such as obesity, risk for surgical site complications is increasing. The objective of this study was to evaluate trends in, risk factors for, and racial disparities related to cesarean complications. Methods: This repeated cross-sectional study evaluated cesarean deliveries in the 2002–2014 National Inpatient Sample for women age 15–54. The primary outcome was a cesarean surgical complication composite including (i) surgical injuries, (ii) reoperation, and (iii) surgical site complications. Surgical injuries, reoperation, and surgical site complications were additionally evaluated individually as outcomes. Univariable and multivariable log linear regression models including demographic, clinical, and hospital factors were performed to assess risk for outcomes with unadjusted and adjusted risk ratios (aRR) with 95% confidence intervals (CI) as measures of association. Temporal trends were estimated using average annual percentage change from a joinpoint regression model. A stratified analysis was performed restricted to non-Hispanic black women. Data was weighted to provide national estimates. Results: A total of 16.2 million estimated cesarean deliveries (3.2 million unweighted cesarean deliveries) from 2002 to 2014 were included in this analysis. The prevalence of the cesarean surgical complication composite was 1.14%, surgical site complications occurred in 0.60%, surgical injuries in 0.49%, and reoperations in 0.10%. Comparing the end of the study (2012–2014) to the beginning of the study (2002–2003), adjusted risk for the composite was similar (aRR 0.93, 95% CI 0.92, 0.95). In comparison, surgical site complication risk was lower at the end of the study (aRR 0.77, 95% CI 0.75, 0.79) while risks for surgical injury (aRR 1.18, 95% CI 1.15, 1.22) and reoperation (1.18, 95% CI 1.10, 1.26) were higher. Non-Hispanic black women were at increased risk for surgical site complications (aRR 1.83, 95% CI 1.80, 1.87) and reoperation (aRR 1.44, 95% CI 1.37, 1.51), but not surgical injury (aRR 0.99, 95% CI 0.97, 1.02). In analyses stratified for non-Hispanic black women, there was a reduction in risk for surgical site complications at the end of the study period compared to the beginning similar to the primary analysis (aRR 0.76, 95% 0.72, 0.81) with a modest decrease in overall risk for the composite outcome (aRR 0.85, 95% CI 0.81, 0.89). Conclusion: A decrease in risk for surgical site complications was offset by slightly increased risk for surgical injury and reoperation in adjusted analyses. Among non-Hispanic black women, surgical site complication risk decreased proportionately with this group still at significantly higher overall risk. [ABSTRACT FROM AUTHOR]

Background Costs for obstetrical care may be increasing for both patients and insurers. Objective To examine predictors of and trends in the cost of medical care during pregnancy. Study design We performed a study of pregnancies from 2009 to 2019 covered by commercial insurance resulting in term, singleton delivery hospitalizations and included in the MarketScan database. The analysis categorized pregnancies based on whether delivery occurred via cesarean versus vaginal delivery and whether pre-gestational diabetes or chronic hypertension was present. We estimated inflation-adjusted total medical costs from 273 days before through 42 days after delivery hospitalization discharge. The analysis evaluated costs for inpatient services, outpatient services, and outpatient drugs separately and trended these costs over the study period. The analysis dichotomized total medical costs into insurer liability versus out-of-pocket patient costs. The study used quantile regression models fit separately to evaluate costs for vaginal and cesarean delivery including demographic and medical characteristics. Results The analysis included 1,952,432 pregnancies covered by commercial insurance. From 2009 to 2019, median total medical costs increased from $14,091 (IQR $11,122–$18,417) to $19,645 (IQR $14,676–$27,959) with median inpatient costs increasing 36% and median outpatient costs increasing 43%. Out-of-pocket costs rose 65% for inpatient services and 120% for outpatient services. Median total pregnancy costs were higher for women with chronic hypertension (median $22,268, IQR $16,809–$30,901, p < .01), pregestational diabetes (median $20,786, IQR $15,702–$28,714, p < .01), and cesarean delivery (median $20,098, IQR $15,748–$26,889 versus median $14,904, IQR $11,728–$19,785 for vaginal delivery, p < .01). In adjusted analyses, chronic hypertension, diabetes, and cesarean delivery were associated with increased median total costs. Conclusion Total and out-of-pocket medical costs for maternity care are increasing among commercially insured patients. Chronic hypertension, pregestational diabetes, and cesarean delivery are important predictors of costs. [ABSTRACT FROM AUTHOR]

Objective: Prior research demonstrated large increased risk for maternal mortality among women with epilepsy. The objective of this study was to estimate risk for adverse maternal outcomes during delivery hospitalizations among women with epilepsy. Methods: Truven Health MarketScan databases were used to compare risk for adverse maternal outcomes during delivery hospitalizations based upon whether there was diagnosis of epilepsy and receipt of anti-epileptic drugs prior to delivery. Outcomes included: (i) death during delivery hospitalization, (ii) severe maternal morbidity, (iii) cesarean delivery, (iv) postpartum hemorrhage, (v) placental abruption, (vi) preeclampsia, (vii) preterm delivery, (viii) premature rupture of membranes, and (ix) stillbirth. Adjusted models including hospital and demographic factors were performed with adjusted risk ratios (aRR) with 95% CIs as measures of effect. Results: Women with epilepsy prior to delivery who received antiepileptic drugs (n = 6019) during pregnancy were not at increased risk for mortality with no deaths occurring in this group (p = .27). Risk for severe maternal morbidity in this group was approximately double (aRR 2.16, 95% CI 1.86–2.51) with risks for other outcomes including placental abruption (aRR 1.29, 95% CI 1.04–1.60), cesarean delivery (aRR 1.14, 95% CI 1.10–1.18), and preterm delivery (aRR 1.25, 95% CI 1.15–1.35) slightly increased compared to women without seizures. Conclusion: No significant difference in mortality risk was found for women with epilepsy. Increased risk for other adverse maternal outcomes for women with epilepsy on antiepileptics was modest. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose To characterize temporal trends and outcomes of delivery hospitalization with maternal congenital heart disease (CHD). Materials and methods For this repeated cross-sectional analysis, deliveries to women aged 15–54 years with maternal CHD were identified in the 2000–2018 National Inpatient Sample. Temporal trends in maternal CHD were analyzed using joinpoint regression to estimate the average annual percentage change (AAPC) with 95% CIs. The relationship between maternal CHD and several adverse maternal outcomes was analyzed with log-linear regression models. Risk for adverse outcomes in the setting of maternal CHD was further characterized based on additional diagnoses of cardiac comorbidity including congestive heart failure, arrhythmia, valvular disease, pulmonary disorders, and history of thromboembolism. Results Of 73,109,790 delivery hospitalizations, 51,841 had a diagnosis of maternal CHD (7.1 per 10,000). Maternal CHD rose from 4.2 to 10.9 per 10,000 deliveries (AAPC 4.8%, 95% CI 4.2%, 5.4%). Maternal CHD deliveries with a cardiac comorbidity diagnosis also increased from 0.6 to 2.6 per 10,000 from 2000 to 2018 (AAPC 8.4%, 95% CI 6.3%, 10.6%). Maternal CHD was associated with severe maternal morbidity (adjusted risk ratios [aRR] 4.97, 95% CI 4.75, 5.20), cardiac severe maternal morbidity (aRR 7.65, 95% CI 7.14, 8.19), placental abruption (aRR 1.30, 95% 1.21, 1.38), preterm delivery (aRR 1.47, 95% CI 1.43, 1.51), and transfusion (aRR 2.28, 95% CI 2.14, 2.42). Risk for severe morbidity (AAPC 4.7%, 95% CI 2.5%, 6.9%) and cardiac severe morbidity (AAPC 4.7%, 95% CI 2.5%, 6.9%) increased significantly among women with maternal CHD over the study period. The presence of cardiac comorbidity diagnoses was associated with further increased risk. Conclusion Maternal CHD is becoming more common among US deliveries. Among deliveries with maternal CHD, risk for severe morbidity is increasing. These findings support that an increasing burden of risk from maternal CHD in the obstetric population. [ABSTRACT FROM AUTHOR]

To determine risk for cardiac readmissions among women without cardiac diagnoses present at delivery up to 9 months after delivery hospitalization discharge. Delivery hospitalizations without cardiac diagnoses were identified from the 2010–2014 Nationwide Readmissions Database and linked with subsequent cardiac hospitalizations over the following 9 months. The temporality of new-onset cardiac hospitalizations was calculated for each 30-day interval from delivery discharge up to 9 months postpartum. Multivariable log-linear regression models were fit to identify risk factors for cardiac readmissions adjusting for patient, medical, and obstetrical factors with adjusted risk ratios as measures of effect (aRR). Among 4.4 million delivery hospitalizations without a cardiac diagnosis, readmission for a cardiac condition within 9 months occurred in 26.8 per 10,000 women. Almost half of readmissions (45.9%) occurred within the first 30 days after delivery discharge with subsequent hospitalizations broadly distributed over the remaining 8 months. Factors such as hypertensive diseases of pregnancy (aRR 2.19, 95% CI 2.09, 2.30), severe maternal morbidity at delivery (aRR 2.06, 95% CI 1.79, 2.37), chronic hypertension (aRR 2.52, 95% CI 2.31, 2.74), lupus (aRR 4.62, 95% CI 3.82, 5.60), and venous thromboembolism during delivery (aRR 3.72, 95% CI 2.75, 5.02) were all associated with increased risk for 9-month postpartum cardiac admissions as were Medicaid (aRR 1.57, 95% CI 1.51, 1.64) and Medicare insurance (aRR 3.06, 95% CI 2.70, 3.46) compared to commercial insurance and maternal ages 35–39 and 40–54 years (aRR 1.24, 95% CI 1.17, 1.32, aRR 1.74, 95% CI 1.60, 1.90, respectively) compared to maternal age 25–29 years. Among women without a cardiac diagnosis at delivery, multiple medical factors and obstetrical complications are associated with development of new cardiac disease requiring readmission in the postpartum period. Given that pregnancy complications and comorbidities may be associated with intermediate-term health outcomes, these findings support the importance of continued health care access after six weeks postpartum. [ABSTRACT FROM AUTHOR]

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. 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. 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). 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. [ABSTRACT FROM AUTHOR]

Vancomycin use for intrapartum GBS prophylaxis is not well characterized. The objective of this study was to describe trends in the use of vancomycin among women undergoing vaginal delivery with group B Streptococcus (GBS) colonization. An administrative inpatient database that includes medications was analyzed to evaluate antibiotic use in women undergoing vaginal delivery hospitalizations complicated by GBS colonization from January 2006 to March 2015. Patients with other obstetric or infectious indications for antibiotics were excluded. Frequency of use of individual antibiotic agents was determined. The Cochran–Armitage test was used to assess temporal trends. An adjusted log-linear regression model accounting for demographic and hospital factors with vancomycin receipt as the outcome was performed with adjusted risk ratios (aRR) and 95% confidence intervals (CI) as the measure of effect. Hospital level variation in administration of vancomycin was also evaluated. 469,717 deliveries met inclusion criteria and were included in this analysis. Use of vancomycin increased from 0.8% of patients in 2006 to 3.8% of patients in the first quarter of 2015. Comparing 2015 to 2006 both the unadjusted (relative risk 4.89 95% CI 4.26–5.60) and adjusted (aRR 4.52 95% 3.94–5.19) models demonstrated significantly increased likelihood of vancomycin administration. In evaluating hospital level vancomycin use, variation was noted with 8.0% of centers administering vancomycin to ≥6.0% of patients. Vancomycin is becoming increasingly commonly used for intrapartum GBS prophylaxis. Further research and quality improvements initiatives are indicated to optimize intrapartum GBS antibiotic prophylaxis. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: Obstetric venous thromboembolism (VTE) is a leading cause of maternal mortality. While hospital discharge data provide a readily accessible means of studying this relatively rare outcome, diagnosis codes are of limited validity. Prior studies have demonstrated that VTE billing codes may be subject to misclassification and false positives and overestimate obstetric VTE risk. Given the public health significance of accurately estimating obstetric VTE, the purpose of this study was to determine to what degree patients received anticoagulants after discharge from a delivery hospitalization associated with an acute VTE diagnosis as pharmacy claims may more accurately assess the incidence of obstetric VTE. Study design: A retrospective cohort study using the MarketScan database was performed using 2008–2014 claims data. We identified women 15–54 years of age diagnosed with acute VTE during a delivery hospitalization. We determined the proportion of women with VTE that received anticoagulants within 60 days of delivery discharge. Only women with ≥60 days of pharmacy benefits after discharge were included. Receipt of low molecular weight and unfractionated heparin, warfarin, and Xa inhibitors was ascertained. Receipt of anticoagulants was analyzed individually based on diagnoses for deep vein thrombosis (DVT), pulmonary embolism (PE), or both. The Chi-square test was performed for categorical comparisons. Results: Of 2,664,951 delivery hospitalizations, 2112 women had a diagnosis of VTE (0.08%) including 236 women with PE alone, 1760 women with DVT alone, and 116 women with both DVT and PE. Of these women, 51.3% (95% CI 49.2–53.4%) received an anticoagulant including 49.5% of women with DVT (95% CI 47.2–51.8%), 50.0% of women with PE (95% CI 43.7–56.3%), and 81.9% of women with both DVT and PE (95% CI 73.9–87.9%). Conclusion: This analysis of pharmacy claims found that estimates for the proportion of deliveries with acute VTE diagnoses that subsequently received anticoagulants was similar to chartconfirmed VTE, albeit in a large population. In addition to previous studies comparing database claims to chart review that showed that the prevalence of VTE was grossly overestimated, these findings support that the proportion of cases with VTE during delivery hospitalization may be approximately half that ascertained with billing codes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to assess how race is associated with adverse maternal outcomes in the setting of preeclampsia.Study design: This retrospective cohort study utilized the National (Nationwide) Inpatient Sample (NIS) from the Agency for Health care Research and Quality for the years 2012-2014. Women aged 15-54 with a diagnosis of preeclampsia were included. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, Native American, other, and unknown. The overall risk for severe morbidity based on Centers for Disease Control and Prevention criteria was analyzed along with the risk for specific outcomes such as stroke, acute heart failure or pulmonary edema, eclampsia, and acute renal failure. The risk for severe morbidity was stratified by comorbid risk and compared by race. Log-linear regression models were created to assess risk for severe morbidity with risk ratios and associated 95% confidence intervals as measures of effect.Results: A total of 101,741 women with preeclampsia from 2012 to 2014 were included in this analysis. The risk for severe morbidity was significantly higher among non-Hispanic black women (9.8%) than non-Hispanic white, Hispanic, and all other women, respectively (6.1, 7.7, and 7.5%, respectively, p < .01). For non-Hispanic black compared to non-Hispanic white, Hispanic, and all other women, risk was higher for stroke (17.1 versus 6.5, 12.7, and 9.3 per 10,000 deliveries, respectively, p < .01) and pulmonary edema or heart failure (56.2 versus 32.7, 30.2, and 38.4 per 10,000 deliveries, respectively, p < .01). Non-Hispanic black women were also more likely than non-Hispanic white women to experience renal failure (136.4 versus 60.4 per 10,000 deliveries, p < .01). Adjusting for comorbidity, black women remained at higher risk for severe morbidity (p < .01). The risk for death was higher for black compared to non-black women (121.8 per 100,000 deliveries, 95% CI 69.7-212.9 versus 24.1 per 100,000 deliveries, 95% CI 14.6-39.8, respectively, p < .01)Conclusion: Black women were at higher risk for severe morbidity and mortality associated with preeclampsia. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to characterize morbidity, acuity, and maternal risks associated with preeclampsia across hospitals with varying obstetric volumes.Methods: This retrospective cohort analysis used a large administrative data source, the Perspective database, to characterize the risk for preeclampsia from 2006 to 2015. Hospitals were classified as having either low (≤1000), moderate (1001-2000), or high (≥2000) delivery volume. The primary outcomes included preeclampsia, antihypertensive administration, comorbidity, and related severe maternal morbidity. Severe maternal morbidity was estimated using criteria from the Centers for Disease Control and Prevention. Comorbidity was estimated using an obstetric comorbidity index. Univariable comparisons were made with Chi-squared test. Adjusted log linear regression models were fit to assess factors associated with severe morbidity with risk ratios with 95% confidence intervals as the measures of effect. Population weights were applied to create national estimates.Results: Of 36,985,729 deliveries included, 1,414,484 (3.8%) had a diagnosis of preeclampsia. Of these, 779,511 (2.1%) had mild, 171,109 (0.5%) superimposed, and 463,864 (1.3%) severe preeclampsia. The prevalence of mild, superimposed, and severe preeclampsia each increased over the study period with severe and superimposed preeclampsia as opposed to mild preeclampsia increasing the most proportionately (53.2 and 102.5 versus 10.8%, respectively). The use of antihypertensives used to treat severe range hypertension increased with use of intravenous labetalol increasing 31.5%, 43.2%, and 36.1% at low-, medium-, and high-volume hospitals. Comorbid risk also increased across hospital volume settings as did risk for severe maternal morbidity.Conclusions: Preeclampsia is increasing across obstetric care settings with preeclamptic patients demonstrating increasing comorbid risk, increased risk for severe morbidity, and more frequent need for treatment of acute hypertension. [ABSTRACT FROM AUTHOR]

Introduction: 17-alpha hydroxyprogesterone caproate (17 P) is a progestin commonly used during pregnancy to reduce risk of recurrent preterm birth. History of thromboembolism is a contraindication to 17 P and the package insert for 17 P recommends discontinuation in the setting of an acute VTE event. The objective of this study was to determine whether 17 P is associated with increased risk of VTE. Study Design: The MarketScan claims database was used to perform a retrospective cohort of women who underwent delivery from 4/2008 to 1/2015. We identified women who received 17 P during pregnancy based on pharmacy benefits. Risk for VTE including deep vein thrombosis, pulmonary embolism, or both was stratified based on the presence or absence of 17 P pharmacy receipt. Both antenatal and delivery hospitalization VTE events were as ceratined and these periods were analyzed individually. Relative risk (RR) was determined based on 17 P receipt. Results: Among 4,775,667 delivery hospitalizations, 18,745 women received 17 P. Among women who did not receive 17 P, 0.52% of women (n = 24,529) had a VTE diagnosis compared to 0.61% (n = 114) receiving 17 P (RR 1.18, 95% CI 0.98–1.42). Comparing VTE events (i) during the antenatal period and (ii) during delivery hospitalizations, risks did not differ significantly for patients receiving 17 P. When risk was restricted to the cohort of patients without a diagnosis of a prior VTE event, 0.30% of women (n = 56) receiving 17 P were diagnosed with an event versus 0.28% of women (n = 13,427) not receiving 17 P (RR 1.07, 95% 0.82–1.39). Discussion: No significant increased risk for VTE was noted with 17 P receipt. While new research has led to reconsideration of clinical use of 17 P for preterm birth prevention based on efficacy, findings from this analysis do not support major risk for thrombosis. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to characterize risk for and temporal trends in postpartum hemorrhage across hospitals with different delivery volumes.Study Design: This study used the Nationwide Inpatient Sample (NIS) to characterize risk for postpartum hemorrhage from 1998 to 2011. Hospitals were classified as having either low, moderate or high delivery volume (≤1000, 1001 to 2000, >2000 deliveries per year, respectively). The primary outcomes included postpartum hemorrhage, transfusion, and related severe maternal morbidity. Adjusted models were created to assess factors associated with hemorrhage and transfusion.Results: Of 55,140,088 deliveries included for analysis 1,512,212 (2.7%) had a diagnosis of postpartum hemorrhage and 361,081 (0.7%) received transfusion. Risk for morbidity and transfusion increased over the study period, while the rate of hemorrhage was stable ranging from 2.5 to 2.9%. After adjustment, hospital volume was not a major risk factor for transfusion or hemorrhage.Discussion: While obstetric volume does not appear to be a major risk factor for either transfusion or hemorrhage, given that transfusion and hemorrhage-related maternal morbidity are increasing across hospital volume categories, there is an urgent need to improve obstetrical care for postpartum hemorrhage. Those risk factors are able to discriminate women at increased risk supports routine use of hemorrhage risk assessment. [ABSTRACT FROM AUTHOR]

Purpose: To determine the association between obstetric outcomes and publicly reported hospital data on patient satisfaction, surgical quality measures and medical outcomes. Materials and methods: Hospitals in the Nationwide Inpatient Sample in 2011 were linked to Hospital Compare, a source of hospital data on patient satisfaction, quality and mortality for medical conditions. The risk-adjusted hospital-level rates of obstetric morbidity, episiotomy and lacerations were compared across the hospitals and reported as the absolute reduction in risk (ARR). Results: We identified 528 708 women. There was no association between any of the metrics and risk-adjusted obstetric morbidity (range -0.15% to 0.03% difference). Hospitals with a high mortality rate for pneumonia had a 0.38% (95% CI: 0.13% to 0.64%) higher rate of risk-adjusted third- and fourth-degree lacerations, while hospitals with a higher death rate for myocardial infarction had a -0.74% (95% CI, -1.34% to -0.14%) lower risk-adjusted episiotomy rate. The differences in the remainder of the publicly reported metrics and the risk adjusted rates of third- and fourth-degree lacerations and episiotomy were small and not statistically significant (p>0.05). Conclusion: There is little association between currently available, publically reported hospital data and obstetric quality. Obstetric-specific hospital measures of quality and satisfaction are needed. [ABSTRACT FROM AUTHOR]

Objective: Universal perioperative mechanical thromboprophylaxis is recommended for patients undergoing cesarean delivery because of increased risk for venous thromboembolism (VTE) associated with this mode of delivery. While research supports clinical benefits from this approach, other specialties have demonstrated suboptimal compliance with prophylaxis device use. The objective of this study was to review patient compliance with sequential compression devices (SCDs).Methods: This cross-sectional observational study utilized data from a prospective quality assurance analysis to evaluate demographic, medical and obstetrical factors associated with postoperative SCD compliance after cesarean delivery. Observations were performed before 7 a.m. on the first postoperative day, a time point when patients were unlikely to be fully ambulatory and would most benefit from device use. The reason for failure was documented in cases where the device was not being properly used.Results: Two hundred and ninety-three patients underwent cesarean delivery, had SCD compliance assessed and were included in the analysis. Twenty one percent of patients (n=60) were non-compliant with SCD use. Reasons for noncompliance included patient discomfort, machine malfunction and incorrect device use. Patients who were non-compliant had similar risk factors for thromboembolism compared to women who were compliant.Conclusion: Although SCD's are effective in preventing thromboembolism, device use was suboptimal in this cohort of post-cesarean patients. These findings are similar to those from other fields. For institutions that rely primarily on mechanical thromboprophylaxis for obstetric patients, quality assurance and auditing of use may be necessary to ensure patients are receiving adequate prophylaxis. For post-cesarean patients with additional VTE risk factors, pharmacologic prophylaxis may be beneficial. [ABSTRACT FROM AUTHOR]

Objective: Given that cesarean delivery is one of the most commonly performed surgical procedures in the United States and an important contributor to obstetric care costs, this analysis sought to examine maternal hospital costs associated with trial of labor after cesarean delivery (TOLAC) versus repeat cesarean delivery (RCD).Methods: A national sample was used to identify women with singleton pregnancy who underwent either TOLAC or RCD from 2006 to 2012. Women with diagnoses that could confound cost via extended hospital length of stay prior to delivery were excluded. Other medical and obstetric covariates that could influence cost were included in an adjusted model.Results: A total of 485,247 women were identified, including 365,596 (75.3%) cesarean deliveries without labor, 41,988 (8.6%) successful and 77,663 (16.0%) unsuccessful TOLAC deliveries. The inflation-adjusted median costs in this cohort were $5512 for cesarean without labor, $4175 for successful TOLAC, $5166 for all TOLAC attempts, and $5759 for failed TOLAC. In a multivariable model, hospital region was a major predictor of median cost as were demographic variables and medical comorbidities.Conclusion: TOLAC is associated with modest reductions of cost for maternal hospitalizations. However, other medical, demographic and hospital factors appear to be more important factors. [ABSTRACT FROM AUTHOR]

Objective: Our survey aimed to identify knowledge and application of guidelines in the United States by assessing practicing obstetricians and gynecologists (OBGYN) use of thromboprophylaxis, preferred methods and whether their type of practice influenced their choices. Study design: A cross-sectional survey of fellows of the American College of Obstetricians and Gynecologists (ACOG) was performed. A 21-item paper and electronic questionnaire was sent to each participant. A total of three mailings were carried out. Results: In total, 400 OBGYN were invited to participate. Questionnaires were returned by 209 (52.3%), 157 (75.1%) of whom provided prenatal care within the last year. All respondents used at least one method of thromboprophylaxis routinely. About 92.4% used pneumatic compression devices. An equal proportion used unfractionated heparin and low molecular weight heparin routinely (17.8%). About 19.1% routinely used combination prophylaxis. In total, 77.1% ( n = 121) used the ACOG guidelines. Local hospital guidelines were referenced by 38.2% ( n = 60). Other guidelines referenced were the ACCP guideline ( n = 34, 21.7%) and several international guidelines ( n = 5, 3.3%). Conclusion: Awareness of the risk of thromboembolism around delivery by cesarean section is high among OBGYN practitioners. Broadening guidelines to encompass all deliveries, not only cesareans, with a focus on identifying the patient at risk, would likely be successful. [ABSTRACT FROM AUTHOR]

Objective: We surveyed obstetricians to determine their knowledge, patterns of care and treatment preferences for women with placenta accreta. Methods: A 27-item survey was mailed to fellows of the American College of Obstetricians and Gynecologists. The survey included demographics, questions regarding knowledge and items to examine practice patterns. Results: Among 994 surveyed practitioners 508 responded including 338 who practiced obstetrics. Among generalists, 23.8% of respondents referred patients with placenta accreta to a sub-specialist. Overall, 20.4% referred women to the nearest tertiary center, and 7.1% referred to a regional center. Delivery was recommended at 34-36 weeks by 41.2%. Adjuvant interventions including ureteral stents (26.3%), iliac artery embolization catheters (28.1%), and balloon occlusion catheters (20.1%) were used infrequently. Six or more units of blood were crossed for delivery by only 29.0% of practitioners. Conclusion: There is widespread variation in the care of women with or at risk for placenta accreta. [ABSTRACT FROM AUTHOR]

Objectives. To evaluate the relationship between low maternal body mass index (BMI) as calculated in the first trimester and the risk of preeclampsia and gestational hypertension. Methods. Patients enrolled in the First And Second Trimester Evaluation of Risk for aneuploidy (FASTER) trial were grouped into three weight categories: low BMI (BMI <19.8 kg/m2), normal BMI (BMI 19.8 - 26 kg/m2), and overweight BMI (26.1 - 29 kg/m2). The incidences of gestational hypertension and preeclampsia were ascertained for each group. Tests for differences in crude incidence proportions were performed using Chi-square tests. Multiple logistic regression was used to adjust for maternal age, race, parity, obesity, use of assisted reproductive technology (ART), in vitro fertilization (IVF), gestational diabetes, pre-gestational diabetes, cocaine use, and smoking. Results. The proportion of patients having gestational hypertension in the low BMI group was 2.0% compared to 3.2% for normal BMI and 6.0% for overweight BMI (p < 0.0001). Women with low BMI were also less likely to develop preeclampsia, 1.1% vs. 1.9% for normal BMI and 2.8% for overweight BMI (p < 0.0001). Conclusions. We found that women with low BMI in the first trimester were significantly less likely to develop gestational hypertension or preeclampsia than women with a normal BMI. [ABSTRACT FROM AUTHOR]