Faculty Bibliography

OBJECTIVE:To assess variation in inpatient antepartum management strategies for placenta accreta spectrum (PAS) disorder and their association with hospitalization costs in a national sample. METHODS:This retrospective cohort study used the 2016-2021 Nationwide Readmissions Database to identify individuals aged 15-54 years who underwent cesarean hysterectomy for PAS between 23 and 35 weeks of gestation. Patients were categorized into four management groups based on whether they had a separate antepartum hospitalization and their predelivery length of stay (LOS) during the delivery hospitalization. Median total hospitalization costs (inclusive of separate antepartum and delivery hospitalization), adjusted to 2023 dollars, were analyzed as continuous and dichotomized outcomes (above the 90th percentile). Unadjusted and adjusted logistic and median regression models assessed whether inpatient management variation, postpartum LOS, demographic, and clinical factors influenced hospitalization costs. RESULTS:Among 3,237 individuals with PAS, 50.5% had no prior antepartum admission and a predelivery LOS of 2 days or less, 31.9% had no prior antepartum admission and a predelivery LOS of more than 2 days, 11.8% had a prior antepartum admission and a predelivery LOS of 2 days or less, and 5.8% had a prior antepartum admission and a predelivery LOS of more than 2 days. Median total hospitalization costs varied significantly by management group, with mean costs ranging from $21,829 to $51,039. Management variation was associated with nearly 3- to 29-times higher likelihood of high total hospitalization costs and $8,907-29,021 adjusted higher median cost depending on the specific management group. Of evaluated clinical factors, only disseminated intravascular coagulation was associated with an adjusted median cost increase of $12,921. CONCLUSION/CONCLUSIONS:Nearly one in five patients with PAS experienced an all-cause antepartum hospitalization. Variation in inpatient admission for management of PAS was evident in this national sample and was a significant driver of hospitalization costs. Although some antepartum hospitalizations and prolonged predelivery lengths of stay are unavoidable due to the complexity and severity of PAS, efforts to reduce unnecessary variations could reduce total hospitalization costs.

BACKGROUND:birthday but its effectiveness in reducing SMM has not been evaluated. OBJECTIVE:To assess the association of the DCP with SMM during delivery hospitalization. STUDY DESIGN/METHODS:Difference-in-differences analysis of US delivery hospitalizations from January 2006 to September 2015, stratified according to maternal race and ethnicity. The outcome was SMM exclusive of blood transfusion only, as defined by the Centers for Disease Control and Prevention criteria. The exposure was maternal age categorized into 21 to 25 years (covered by the DCP) and 27 to 31 years (not covered the DCP). The intervention was the DCP categorized into pre- and post-DCP periods (January 2006-September 2010 and October 2010-September 2015, respectively). RESULTS:Of the 4,007,937 delivery hospitalizations in the sample, 22,540 (56.2 per 10,000) recorded SMM. For birthing people aged 21 to 25 years (covered by the DCP), the mean SMM rate was 48.9 per 10,000 during the pre-DCP period and 58.2 per 10,000 during the post-DCP period (crude difference: 9.3 per 10,000). For birthing people aged 27 to 31 years (not covered the DCP), the mean SMM rate was 53.4 per 10,000 during the pre-DCP period and 63.6 per 10,000 during the post-DCP period (crude difference: 10.2 per 10,000). Implementation of DCP was associated with a 1.2% (95% CI: -3.6, 1.3) relative decrease in the mean SMM rate (adjusted odds ratio (aOR): 0.988; 95% CI: 0.964, 1.013). For non-Hispanic White people, the DCP was associated with a 10.7% (95% CI: 7.1, 14.2) relative decrease in the mean SMM rate (aOR: 0.893; 95% CI: 0.858, 0.929). The DCP was associated with an increase in the proportion of privately insured (aOR: 1.225; 95% CI: 1.220, 1.231), a decrease in the proportion of Medicaid beneficiaries (aOR: 0.853; 95% CI: 0.849, 0.856), and a decrease in the proportion of uninsured (aOR: 0.807; 95% CI: 0.798, 0.816). CONCLUSIONS:Maternal health benefit of the DCP appears to be limited to non-Hispanic White birthing people.

In 2021, the severe acute respiratory syndrome coronavirus 2 Delta variant rapidly proliferated and became dominant. Some but not all research evidence supports that Delta was associated with increased maternal risk. The purpose of this study was to determine whether Delta was associated with risk for cardiac and respiratory complications in a national sample. Of an estimated 3,495,188 delivery hospitalizations in 2021, 1.8% of pre-Delta deliveries (n = 29,580; January-June) and 2.1% of Delta-period deliveries (n = 37,545; July-December) had a coronavirus disease 2019 (COVID-19) diagnosis. The Delta period was associated with increased adjusted odds of respiratory complications (adjusted odds ratio [aOR] = 1.54, 95% CI: 1.41, 1.69) and cardiac severe maternal morbidity (SMM; aOR = 1.54, 95% CI: 1.40, 1.69). Among deliveries with a COVID-19 diagnosis, the Delta period was associated with a higher incidence of respiratory complications (8.4 vs. 3.7%) and cardiac SMM (8.4 vs. 3.5%; p < 0.01 for both). These findings corroborate prior clinical studies suggesting that the Delta strain was associated with an increased maternal population-level clinical burden. · The Delta strain was associated with an increased maternal population-level clinical burden.. · The Delta period was associated with an increased risk for cardiac and respiratory complications.. · Among deliveries with a COVID-19 diagnosis, the Delta period was associated with increased risk..

BACKGROUND/UNASSIGNED:While guideline-based multidisciplinary care is increasingly emphasized for managing von Willebrand disease (VWD) in pregnancy, most outcomes data are derived from outdated studies. OBJECTIVES/UNASSIGNED:This study aimed to evaluate temporal trends in the prevalence of VWD, estimate hemorrhagic complication trends with VWD, and examine associations with adverse pregnancy outcomes with VWD. METHODS/UNASSIGNED:We conducted a cross-sectional analysis leveraging data from the National Inpatient Sample from 2000 to 2022 and identified VWD delivery hospitalizations using International Classification of Diseases codes. Outcomes included placental abruption or antepartum hemorrhage, postpartum hemorrhage, transfusion, nontransfusion severe maternal morbidity, and cesarean and operative vaginal delivery. Joinpoint regression was used to analyze trends by estimating the average annual percentage change. Unadjusted and adjusted logistic regression models were used to determine the strength of association between VWD and adverse pregnancy outcomes. RESULTS/UNASSIGNED:Among 87,151,596 delivery hospitalizations, 4.2 per 10,000 had a diagnosis of VWD. VWD prevalence rose from 2.1 to 5.1 per 10,000 deliveries between 2000 and 2022 (average annual percentage change, 6.6%; 95% CI, 5.3%-19.5%). Delivery hospitalizations with VWD were associated with increased rates of antepartum hemorrhage, postpartum hemorrhage, transfusion, nontransfusion severe maternal morbidity, and cesarean delivery. Of these associations, during the study period for deliveries with VWD, rates of antepartum hemorrhage and transfusion decreased significantly, and delivery route showed a decrease in operative vaginal delivery. CONCLUSION/UNASSIGNED:Declining transfusion and antepartum hemorrhage rates suggest improvements in diagnosis and management of VWD during pregnancy. However, stable rates of postpartum hemorrhage rate highlight continued gaps in care. These contemporary, population-level findings will inform preconception counseling and intrapartum planning for individuals with VWD.

Hypertensive disorders of pregnancy (HDP) may account for a considerable and growing clinical burden at rural hospitals which have been providing fewer obstetric services over the past two decades. The objectives of this analysis were to evaluate trends, risk factors, and outcomes associated with HDP during delivery hospitalizations at rural hospitals in the United States.The 2000 to 2020 National Inpatient Sample was used for this repeated-cross sectional analysis. Delivery hospitalizations at rural hospitals to women 15 to 54 years of age with and without HDP (including preeclampsia and gestational hypertension) were identified. Trends in HDP were characterized with joinpoint regression and estimated as the average annual percent change (AAPC) with 95% confidence intervals (CIs). The associations between (i) HDP risk factors and HDP and (ii) HDP and adverse maternal outcomes were estimated with adjusted logistic regression models.Among 8,885,683 deliveries that occurred at rural hospitals, the proportion with a HDP diagnosis increased significantly from 6.0% in 2000 to 11.1% in 2020 (AAPC: 3.1%; 95% CI: 2.8 and 3.4%). Preeclampsia with severe features (AAPC: 5.5%; 95% CI: 4.8 and 6.2%) and superimposed preeclampsia (AAPC: 6.5%; 95% CI: 5.6 and 7.5%) underwent the largest relative increases over the study period. Obesity, pregestational diabetes, chronic hypertension, multiple gestation, and chronic kidney disease were all associated with increased adjusted odds of HDP. HDP diagnoses were significantly associated with severe maternal morbidity (SMM), transfusion, stroke, and disseminated intravascular coagulation. The proportion of overall delivery SMM associated with HDP more than doubled from 11.3% in 2000 to 24.7% in 2020.Among delivery hospitalizations at rural hospitals, HDP, and associated risk factors increased significantly over the study period. Deliveries with HDP accounted for an increasing proportion of population-level SMM. HDP is a major, growing contributor to maternal risk and adverse outcomes during deliveries at rural hospitals. · Hypertensive disorders accounted for an increasing proportion of population-level severe morbidity.. · Hypertensive disorders increased among rural delivery hospitalizations.. · Risk factors associated with hypertensive disorders increased among rural delivery hospitalizations..

BACKGROUND:Given the risks associated with congenital heart disease in the postpartum period, epidemiologic data identifying risk factors and timing of complications may be useful in improving postpartum care. OBJECTIVE:This study aimed to determine the timing of, risk factors for, and complications associated with 60-day postpartum readmissions following deliveries with maternal congenital heart disease. STUDY DESIGN/METHODS:The 2010-2020 Nationwide Readmissions Database was used for this retrospective cohort study. Postpartum readmissions occurring within 60 days of delivery hospitalization discharge were ascertained. Clinical, demographic, and hospital risk factors associated with postpartum readmission were analyzed using logistic regression models, with unadjusted and adjusted odds ratios as measures of association. Among patients with congenital heart disease, the role of additional cardiac risk factors in the likelihood of readmission was analyzed. Risks for adverse maternal outcomes during readmission were analyzed, including severe maternal morbidity, cardiac severe maternal morbidity, and a critical care composite. RESULTS:Of an estimated 40,780,439 delivery hospitalizations, 35,242 had an associated congenital heart disease diagnosis (8.6 per 10,000), including 2279 (6.5%) with complex congenital heart disease and 32,963 (93.5%) with noncomplex congenital heart disease. The proportion of deliveries with a maternal congenital heart disease diagnosis increased significantly from 6.7 per 10,000 in 2010 to 11.8 in 2020. Overall risk for 60-day postpartum readmission was 1.6% among women without congenital heart disease and 3.1% among women with congenital heart disease (P<.01). Among women with congenital heart disease, 36.0% of 60-day postpartum readmissions occurred 1 to 5 days after discharge, 18.0% 5 to 10 days after discharge, and 14.5% 10 to 20 days after discharge. In adjusted models for the entire population, congenital heart disease retained a significant association with 60-day postpartum readmission (adjusted odds ratio, 1.73; 95% confidence interval, 1.55-1.94). When the cohort was restricted to deliveries with congenital heart disease, adjusted analyses demonstrated increased odds associated with additional cardiac risk factors (congestive heart failure: adjusted odds ratio, 1.72; 95% confidence interval, 1.13-2.62; arrhythmia: adjusted odds ratio, 1.68; 95% confidence interval, 1.27-2.21; pulmonary circulation disorders: adjusted odds ratio, 1.57; 95% confidence interval, 1.10-2.24; and chronic hypertension: adjusted odds ratio, 1.88; 95% confidence interval, 1.26-2.80), hypertensive disorders of pregnancy (adjusted odds ratio, 1.97; 95% confidence interval, 1.49-2.61), and cesarean delivery (primary adjusted odds ratio, 1.82; 95% confidence interval, 1.39-2.38; repeat cesarean: adjusted odds ratio, 1.91; 95% confidence interval, 1.42-2.55). The risk of adverse outcomes during readmissions was higher for women with congenital heart disease than for those without (severe maternal morbidity: 23.8% vs 16.1%; P<.01; cardiac severe maternal morbidity: 9.6% vs 4.9%; P<.01; and a critical care composite: 3.1% vs 1.8%; P<.01). CONCLUSION/CONCLUSIONS:Deliveries with congenital heart disease were associated with increased odds of postpartum readmission and complications during readmissions. Most readmissions occurred soon after delivery discharge. Among patients with congenital heart disease, risk for readmission was higher in the setting of additional cardiac risk factors, hypertensive disorders of pregnancy, and cesarean delivery.

OBJECTIVE:To determine risks for non-transfusion severe maternal morbidity and transfusion during a second delivery hospitalisation based on clinical risk factors and obstetric complications from an index, first delivery hospitalisation. DESIGN/METHODS:Retrospective cohort. POPULATION/METHODS:Delivery hospitalisations in the 2010-2017 New York State Inpatient Database. METHODS:Patients with a first index delivery hospitalisation followed by a second delivery hospitalisation during the study period were included. Clinical risk factors and obstetric complications were obtained from the first index delivery hospitalisation. Adjusted logistic regression models for non-transfusion severe maternal morbidity during the second delivery were performed with adjusted (aORs) odds ratios as measures of effect. These analyses were then repeated for the outcome of transfusion. RESULTS:Of 624 500 paired delivery hospitalisations to 312 250 women, severe maternal morbidity occurred among 0.85% of second deliveries (n = 2672). When adjusted analysis was performed, several clinical factors were associated with severe maternal morbidity in a subsequent pregnancy, including severe maternal morbidity during the index pregnancy (aOR 8.4, 95% CI 7.0, 9.9), transfusion (aOR 2.0, 95% CI 1.6, 2.4) and pregestational diabetes (aOR 2.2, 95% 1.6, 2.9). When analyses were repeated for transfusion, several factors were associated with increased risk, including severe maternal morbidity (aOR 1.5, 95% CI 1.2, 1.8), index transfusion (aOR 6.3, 95% CI 5.6, 7.0), chronic heart disease (aOR 1.6, 95% 1.4, 1.9) and pregestational diabetes (aOR 1.7, 95% 1.3, 2.2). CONCLUSION/CONCLUSIONS:Many obstetric complications and chronic conditions identified during an index delivery hospitalisation are associated with severe morbidity during a second, subsequent delivery. Index severe maternal morbidity is associated with the highest odds. These findings may be of use in patient counselling and risk stratification.