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BACKGROUND: Postpartum readmission is an important indicator of postpartum morbidity. The likelihood of postpartum readmission is highest for Black individuals. However, it is unclear whether the likelihood of postpartum readmission has changed over time according to race/ethnicity. Little is also known about the factors that contribute to these trends. OBJECTIVE: This study aimed to: (1) examine trends in postpartum readmission by race/ethnicity, (2) examine if prenatal or clinical factors explain the trends, and (3) investigate if racial/ethnic disparities changed over time. STUDY DESIGN: We examined trends in postpartum readmission, defined as hospitalization within 42 days after birth hospitalization discharge, using live birth and fetal death certificates linked to delivery discharge records from 10,711,289 births in California from 1997 to 2018. We used multivariable logistic regression models that included year and year-squared (to allow for nonlinear trends), overall and stratified by race/ethnicity, to estimate the annual change in postpartum readmission during the study period, represented by odds ratios and 95% confidence intervals. We then adjusted models for prenatal (eg, patient demographics) and clinical (eg, gestational age, mode of birth) factors. To determine whether racial/ethnic disparities changed over time, we calculated risk ratios for 1997 and 2018 by comparing the predicted probabilities from the race-specific, unadjusted logistic regression models. RESULTS: The overall incidence of postpartum readmission was 10 per 1000 births (17.4/1000 births for non-Hispanic Black, 10/1000 for non-Hispanic White, 7.9/1000 for non-Hispanic Asian/Pacific Islander, and 9.6/1000 for Hispanic individuals). Odds of readmission increased for all groups during the study period; the increase was greatest for Black individuals (42% vs 21%-29% for the other groups). After adjustment for prenatal and clinical factors, the increase in odds was similar for Black and White individuals (12%). The disparity in postpartum readmission rates relative to White individuals increased for Black individuals (risk ratio, 1.68 in 1997 and 1.90 in 2018) and more modestly for Hispanic individuals (risk ratio, 1.02 in 1997 and 1.05 in 2018) during the study period. Asian/Pacific Islander individuals continued to have lower risk than White individuals during the study period (risk ratio, 0.87 in 1997 and 0.82 in 2018). CONCLUSION: The rate of postpartum readmissions increased from 1997 to 2018 in California across all racial/ethnic groups, with the greatest increase observed for Black individuals. Racial/ethnic differences in the trend were more modest after adjustment for prenatal and clinical factors. It is important to find ways to prevent further increases in postpartum readmission, especially among groups at highest risk.

BackgroundDetermining the accuracy of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes for postpartum hemorrhage (PPH) is vital for reaching valid conclusions about the epidemiology of PPH. Our primary objectives were to assess the performance characteristics of ICD-9 PPH codes against a reference standard using estimated blood loss (EBL) among a cohort undergoing Cesarean delivery.Study design and methodsWe analyzed maternal discharge and EBL data from women who underwent Cesarean delivery at Kaiser Permanente Northern California facilities between 2010 and 2013. We defined PPH as an EBL of at least 1000 mL. In a secondary analysis, ICD-9 performance characteristics were assessed using an EBL of at least 1500 mL to classify severe PPH.ResultsWe identified 35,614 hospitalizations for Cesarean delivery. Using EBL of at least 1000 mL as the "gold standard," PPH codes had a sensitivity of 27.8%, specificity of 97%, positive predictive value (PPV) of 74.5%, and a negative predictive value (NPV) of 80.9%. The prevalence of a PPH code (9%) was lower than the prevalence using a blood loss of at least 1000 mL (24%). Using a reference standard of EBL of at least 1500 mL, PPH codes had a sensitivity of 61.7%, specificity of 93.8%, PPV of 34.2%, and NPV of 97.9%.ConclusionPPH ICD-9 codes have high specificity, moderately high PPVs and NPVs, and low sensitivity. An EBL of at least 1500 mL as a reference standard has higher sensitivity. Our findings suggest that, for women undergoing Cesarean delivery, quality improvement efforts are needed to enhance PPH ICD-9 coding accuracy in administrative data sets.

BackgroundPostpartum anemia is associated with maternal and perinatal morbidity. Population-level data may inform guideline development for postpartum anemia screening. Our objectives were to evaluate the associations between potential predictors (predelivery anemia and postpartum hemorrhage [PPH]) with severe postpartum anemia after Cesarean section.Study design and methodsData were collected from 70,939 hospitalizations for Cesarean section performed at Kaiser Permanente Northern California facilities between 2005 and 2013. Severe postpartum anemia was defined as a hemoglobin (Hb) level of less than 8 g/dL before hospital discharge. Using multivariable logistic regression, we assessed the associations between predelivery anemia and PPH with severe postpartum anemia. Distributions of these characteristics among women with severe postpartum anemia were evaluated.ResultsThe overall rate of severe postpartum anemia was 7.3% (95% confidence interval [CI], 7.1%-7.4%). Severe postpartum anemia was strongly associated with a predelivery Hb level between 10 and 10.9 g/dL (adjusted odds ratio [aOR], 5.4; 95% CI, 4.89-5.91), predelivery Hb level of less than 10 g/dL (aOR, 30.6; 95% CI, 27.21-34.6), and PPH (aOR, 8.45; 95% CI, 7.8-9.16). The proportions of women with severe postpartum anemia were highest for those experiencing PPH but no predelivery anemia (12.2%; 95% CI, 11.0%-13.6%) and those who did not incur PPH nor predelivery anemia (10.7%; 95% CI, 9.6%-12.0%).ConclusionsOur findings suggest that PPH and predelivery anemia are strong independent risk factors for severe postpartum anemia. Optimization of patients' Hb before delivery may reduce the incidence of severe anemia after Cesarean section.

Background: The 10th revision of the International Classification of Diseases, Clinical Modification (ICD‐10) includes diagnosis codes for placenta accreta spectrum for the first time. These codes could enable valuable research and surveillance of placenta accreta spectrum, a life‐threatening pregnancy complication that is increasing in incidence. Objective: We sought to evaluate the validity of placenta accreta spectrum diagnosis codes that were introduced in ICD‐10 and assess contributing factors to incorrect code assignments. Methods: We calculated sensitivity, specificity, positive predictive value and negative predictive value of the ICD‐10 placenta accreta spectrum code assignments after reviewing medical records from October 2015 to March 2020 at a quaternary obstetric centre. Histopathologic diagnosis was considered the gold standard. Results: Among 22,345 patients, 104 (0.46%) had an ICD‐10 code for placenta accreta spectrum and 51 (0.23%) had a histopathologic diagnosis. ICD‐10 codes had a sensitivity of 0.71 (95% CI 0.56, 0.83), specificity of 0.98 (95% CI 0.93, 1.00), positive predictive value of 0.61 (95% CI 0.48, 0.72) and negative predictive value of 1.00 (95% CI 0.96, 1.00). The sensitivities of the ICD‐10 codes for placenta accreta spectrum subtypes— accreta, increta and percreta—were 0.55 (95% CI 0.31, 0.78), 0.33 (95% CI 0.12, 0.62) and 0.56 (95% CI 0.31, 0.78), respectively. Cases with incorrect code assignment were less morbid than cases with correct code assignment, with a lower incidence of hysterectomy at delivery (17% vs 100%), blood transfusion (26% vs 75%) and admission to the intensive care unit (0% vs 53%). Primary reasons for code misassignment included code assigned to cases of occult placenta accreta (35%) or to cases with clinical evidence of placental adherence without histopatholic diagnostic (35%) features. Conclusion: These findings from a quaternary obstetric centre suggest that ICD‐10 codes may be useful for research and surveillance of placenta accreta spectrum, but researchers should be aware of likely substantial false positive cases. [ABSTRACT FROM AUTHOR]

Anesthesiologists are critical members of the multidisciplinary team managing patients with suspected placenta accreta spectrum (PAS). Preoperatively, anesthesiologists provide predelivery consultation for patients with suspected PAS where anesthetic modality and invasive monitor placement is discussed. Additionally, anesthesiologists carefully assess patient and surgical risk factors to choose an anesthetic plan and to prepare for massive intraoperative hemorrhage. Postoperatively, the obstetric anesthesiologist hold unique skills to assist with postoperative pain management for cesarean hysterectomy. We review the unique aspects of peripartum care for patients with PAS who undergo cesarean hysterectomy and explain why these responsibilities are critical for achieving successful outcomes for patients with PAS. Key Points Anesthesiologists are critical members of the multidisciplinary team planning for patients with suspected placenta accreta spectrum. Intraoperative preparation for massive hemorrhage is a key component of anesthetic care for patients with PAS. Obstetric anesthesiologists have a unique skill set to manage postpartum pain and postoperative disposition for patients with PAS who undergo cesarean hysterectomy. [ABSTRACT FROM AUTHOR]

Since its first description early in the 20th Century, placenta accreta and its variants have changed substantially in incidence, risk factor profile, clinical presentation, diagnosis and management. While systematic use of diagnostic tools and a multidisciplinary team care approach has begun to improve patient outcomes, the condition's pathophysiology, epidemiology, and best practices for diagnosis and management remain poorly understood. The use of large databases with broadly accepted terminology and diagnostic criteria should accelerate research in this area. Future work should focus on non-traditional phenotypes, such as those without placenta previa–preventive strategies, and long term medical and emotional support for patients facing this diagnosis. Key Points Placenta accreta spectrum research may be improved with standardized terminology and use of large databases. Placenta accreta prediction should move beyond ultrasound with the addition of biomarkers, and needs to extend to those without traditional risk factors. Future research should identify practices that can prevent future accreta development. [ABSTRACT FROM AUTHOR]