Faculty Bibliography

OBJECTIVE:This study aimed to assess risk for postpartum psychiatric admissions in the United States. STUDY DESIGN:This study used the 2010 to 2014 Nationwide Readmissions Database to identify psychiatric admissions during the first 60 days after delivery hospitalization. Timing of admission after delivery discharge was determined. We fit multivariable log-linear regression models to assess the impact of psychiatric comorbidity on admission risk, adjusting for patient, obstetrical, and hospital factors. RESULTS:Of 15.7 million deliveries from 2010 to 2014, 11,497 women (0.07%) were readmitted for a primary psychiatric diagnosis within 60 days postpartum. Psychiatric admissions occurred relatively consistently across 10-day periods after delivery hospitalization discharge. Psychiatric diagnoses were present among 5% of women at delivery but 40% of women who were readmitted postpartum for a psychiatric indication. In the adjusted model, women with psychiatric diagnoses at delivery hospitalization were 9.7 times more likely to be readmitted compared with those without psychiatric comorbidity. Women at highest risk for psychiatric admission were those with Medicare and Medicaid, in lower income quartiles, and of younger age. CONCLUSION:While a large proportion of psychiatric admissions occurred among a relatively small proportion of at-risk women, admissions occurred over a broad temporal period relative to other indications for postpartum admission.

OBJECTIVES:To determine the impact of frailty on postoperative readmission, morbidity, and mortality among patients undergoing surgery for endometrial cancer. METHODS:Patients with endometrial cancer undergoing hysterectomy between 2010 and 2014 were identified using the Nationwide Readmissions Database. Frailty was classified using criteria outlined by the Johns Hopkins Adjusted Clinical Groups Frailty Diagnoses Indicators. Primary outcomes were divided by index surgical admission (intensive level of care, mortality, non-routine discharge), 30-days (readmission and mortality), and 90-days (readmission and mortality) after discharge. Multivariable log linear regression models were fit to analyze the effect of frailty on these outcomes, adjusting for patient, hospital, and clinical factors. RESULTS:From 2010 to 2014, there were 144,809 surgical endometrial cancer cases with a 1.8% frailty rate. Frailty was associated with an increased risk of intensive level of care (aRR = 3.61, 95% CI: 2.95, 4.42), non-routine discharge (aRR = 1.59, 95% CI: 1.51, 1.68), and inpatient mortality (aRR = 2.05, 95% CI: 1.68, 2.51) during index admission. Frail patients were more likely to be readmitted within 30 days (RR 1.33, 95% CI 1.22-1.47) and 90-days (RR 1.21, 95% CI 1.12, 1.32), and were at increased risk of mortality during their 30-day readmission (aRR = 1.75, 95% CI: 1.28-2.39). Frailty was not associated with 90-day mortality. Hospitalization costs for frail patients were significantly higher than for non-frail patients during index admission and readmissions within 30 and 90 days (p < 0.05 for all). CONCLUSIONS:Frailty affects postoperative outcomes in endometrial cancer patients and is associated with an increased rate of readmission and 30-day mortality among those who are readmitted. Gynecologic cancer providers should screen for frailty and consider outcomes in frail patients when counseling them for surgery.

OBJECTIVE:To characterise medical, obstetric and demographic risk factors associated with nulliparous, term, singleton, vertex (NTSV) caesarean birth. STUDY DESIGN:Cross-sectional study. SETTING:United States delivery hospitalisations. POPULATION:NTSV births in 2016-18 US natality data. METHODS:This study analysed a national sample of natality data generated by the United States National Vital Statistics System. NTSV deliveries were identified. The primary outcome was caesarean birth. Risk factors including maternal age, body mass index (BMI) and pregestational diabetes were analysed. Multivariable log-linear regression models analysed factors associated with NTSV caesarean with adjusted risk ratios (aRR) as measures of effect. RESULTS:Of 11 622 400 deliveries, 3 764 707 met NTSV criteria, and their caesarean section rate was 25.9%. Maternal age 35-39 years (aRR 1.51, 95% CI 1.50-1.52) and 40-54 years (aRR 2.03, 95% 2.00-2.05) compared with age 19-34 years; BMI 25 to <30 kg/m2 (aRR 1.32, 95% CI 1.31-1.33), 30 to <35 kg/m2 (aRR 1.57 95% CI 1.56-1.58), 35 to <40 kg/m2 (aRR 1.82, 95% CI 1.80-1.83) and ≥40 kg/m2 (aRR 2.17, 95% CI 2.15-2.19) compared with BMI 18.5-24.9 kg/m2; and pregestational diabetes (aRR 1.54, 95% CI 1.51-1.57) were all associated with increased risk. Risk factors allowed stratification of patients into high-risk versus low-risk groups. The NTSV caesarean rate was 37.9% in women who had one or more of the following characteristics: age ≥35 years, BMI ≥30 kg/m2 or pregestational diabetes. In comparison, the NTSV caesarean rate was 20.8% among women without any of these three risk factors (P < 0.01). CONCLUSION:Among NTSV births, BMI, maternal age and medical conditions are important risk factors for caesarean delivery.

BACKGROUND:Need for critical care during delivery hospitalizations may be an important maternal outcome measure, but it is not well characterized. OBJECTIVE:This study aimed to characterize the risks and disparities in critical care diagnoses and interventions during delivery hospitalizations. STUDY DESIGN:This serial cross-sectional study used the 2000-2014 National Inpatient Sample. Here, the primary outcome was a composite of critical care interventions and diagnoses, including mechanical ventilation and intubation, central monitoring, septicemia, coma, acute cerebrovascular disease, extracorporeal membrane oxygenation, Swan-Ganz catheter monitoring, cardiac rhythm conversion, and respiratory failure. Temporal trends, risk of death, and the proportion of deaths with a critical care composite diagnosis were determined. Unadjusted and adjusted log-linear regression models were fit with a critical care composite as the outcome, adjusting for demographic, clinical, and hospital factors. To evaluate the role of critical care interventions in disparities, analyses were stratified by maternal race and ethnicity. RESULTS:Of 45.8 million deliveries identified, 0.21% had a critical care procedure or diagnosis during the delivery hospitalization. Overall, 75.8% of maternal deaths had an associated diagnosis from a critical care composite. The critical composite increased from 17.9 to 30.3 per 10,000 deliveries from 2000 to 2014 with an average annual percentage change of 3.4% (95% confidence interval, 1.3-5.5). Mechanical ventilation and intubation (21.5% of cases) and respiratory failure (54.8% of cases) were the most common diagnoses present in the composite. Although non-Hispanic black women were at 32.4% higher risk than non-Hispanic white women to die in the setting of a critical care diagnosis (2.2% vs 1.7%; P<.01), they were 162% more likely to have a critical care diagnosis (risk ratio, 2.62; 95% confidence interval, 2.58-2.66). Of clinical factors, primary cesarean delivery (adjusted relative risk, 7.54; 95% confidence interval, 7.43-7.65), postpartum hemorrhage (adjusted relative risk, 5.11; 95% confidence interval, 5.02-5.19), and chronic kidney disease (adjusted relative risk, 4.06; 95% confidence interval, 3.89-4.23) were associated with the highest adjusted risk of a critical care composite. CONCLUSION:Three-quarters of maternal deaths were associated with a critical care diagnosis or procedure. The rate of critical care during delivery hospitalizations increased over the study period. Maternal mortality disparities may result from risks of conditions that require critical care rather than the care received once a critical care condition has developed.

BACKGROUND:Black-serving hospitals are associated with increased maternal risk. However, prior administrative data research on maternal disparities has generally included limited hospital factors. More detailed evaluation of hospital factors related to obstetric outcomes may be important in understanding disparities. OBJECTIVE:To examine detailed characteristics of Black-serving hospitals and how these characteristics are associated with risk for severe maternal morbidity (SMM). METHODS:This serial cross-sectional study linked the 2010-2011 Nationwide Inpatient Sample and the 2013 American Hospital Association Annual Survey Databases. Delivery hospitalizations occurring to women 15-54 years of age were identified. The proportions of non-Hispanic Black patients within a hospital was categorized into quartiles, and hospital factors such as specialized medical, surgical and safety-net services as well as payer mix were compared across these quartiles. A series of models was performed evaluating risk for SMM with Black-serving hospital quartile as the primary exposure. Log linear regression models with a Poisson distribution (and robust variance) were performed with unadjusted and adjusted risk ratios (aRR) with 95% confidence intervals (CIs) as measures of effect. RESULTS:(aRR 1.29, 95% CI 1.07, 1.55) quartiles. CONCLUSION:Black-serving hospitals were more likely to provide a range of specialized medical, surgical, and safety-net services and to have a higher Medicaid burden. Payer mix and unmeasured confounding may account for some of the maternal risk associated with Black-serving hospitals.

OBJECTIVE:To analyze racial and ethnic disparities in failure to rescue (ie, death) associated with severe maternal morbidity and describe temporal trends. METHODS:This was a retrospective cohort study using administrative data. Data for delivery hospitalizations with severe maternal morbidity, as defined by the Centers for Disease Control and Prevention, were abstracted from the 1999-2017 National Inpatient Sample. Race and ethnicity were categorized into non-Hispanic White (reference), non-Hispanic Black, Hispanic, other, and missing. The outcome was failure to rescue from severe maternal morbidity. Disparities were assessed using the failure-to-rescue rate ratio (ratio of the failure-to-rescue rate in the racial and minority group to the failure-to-rescue rate in White women), adjusted for patient and hospital characteristics. Temporal trends in severe maternal morbidity and failure to rescue were assessed. RESULTS:During the study period, 73,934,559 delivery hospitalizations were identified, including 993,864 with severe maternal morbidity (13.4/1,000; 95% CI 13.3-13.5). Among women with severe maternal morbidity, 4,328 died (4.3/1,000; 95% CI 4.2-4.5). The adjusted failure-to-rescue rate ratio was 1.79 (95% CI 1.77-1.81) for Black women, 1.39 (95% CI 1.37-1.41) for women of other race and ethnicity, 1.43 (95% CI 1.42-1.45) for women with missing race and ethnicity data, and 1.08 (95% CI 1.06-1.09) for Hispanic women. During the study period, the severe maternal morbidity rate increased significantly in each of the five racial and ethnic groups but started declining in 2012. Meanwhile, the failure-to-rescue rate decreased significantly during the entire study period. CONCLUSION:Despite improvement over time, failure to rescue from severe maternal morbidity remains a major contributing factor to excess maternal mortality in racial and ethnic minority women.

PURPOSE OF REVIEW:Risk factors for obstetric venous thromboembolism (VTE), a leading cause of maternal mortality in the United States, are increasing on a population basis. This review provides the obstetrician with an update of current issues related to obstetric VTE risk, prophylaxis, outcomes, anaesthesia considerations and future research opportunities. RECENT FINDINGS:Obstetric VTE affects approximately 1 per 1000 pregnancies and accounts consistently for 9-10% of maternal deaths in the United States. In industrialized countries, risk factors for VTE, including overweight/obesity, caesarean delivery and obstetrical complications such postpartum haemorrhage and infection continue to increase. VTE prophylaxis is central to reducing maternal mortality. However, recommendations for prophylaxis from leadership societies vary widely. In the UK, maternal mortality risk from VTE has decreased significantly in the setting of broader heparin prophylaxis. In the United States where mechanical VTE prophylaxis is used more commonly, mortality risk has remained constant. SUMMARY:Obstetric VTE is a leading cause of maternal mortality in the United States. The incidence of risk factors for obstetric VTE continues to increase. Currently, recommendations for obstetric VTE prophylaxis vary substantially. Opportunities for research in this area exist to optimize prophylaxis and improve maternal outcomes.

OBJECTIVE:This study was aimed to review 4 weeks of universal novel coronavirus disease 2019 (COVID-19) screening among delivery hospitalizations, at two hospitals in March and April 2020 in New York City, to compare outcomes between patients based on COVID-19 status and to determine whether demographic risk factors and symptoms predicted screening positive for COVID-19. STUDY DESIGN:This retrospective cohort study evaluated all patients admitted for delivery from March 22 to April 18, 2020, at two New York City hospitals. Obstetrical and neonatal outcomes were collected. The relationship between COVID-19 and demographic, clinical, and maternal and neonatal outcome data was evaluated. Demographic data included the number of COVID-19 cases ascertained by ZIP code of residence. Adjusted logistic regression models were performed to determine predictability of demographic risk factors for COVID-19. RESULTS: < 0.01). COVID-19 was associated with higher risk for diagnoses of chorioamnionitis and pneumonia and fevers without a focal diagnosis. In adjusted analyses, including demographic factors, logistic regression demonstrated a c-statistic of 0.71 (95% confidence interval [CI]: 0.69, 0.80). CONCLUSION:COVID-19 symptoms were present in a minority of COVID-19-positive women admitted for delivery. Significant differences in obstetrical outcomes were found. While demographic risk factors demonstrated acceptable discrimination, risk prediction does not capture a significant portion of COVID-19-positive patients. KEY POINTS:· COVID-19 symptoms were present in a minority of COVID-19-positive women admitted.. · COVID-19 symptomatology did not appear to differ before or after the apex of infection in New York.. · Demographic risk factors are unlikely to capture a significant portion of COVID-19-positive patients..

OBJECTIVE:This study aimed to determine whether race and ethnicity contribute to risks associated with peripartum hysterectomy. STUDY DESIGN:This retrospective cross-sectional study utilized the 2000-2014 Nationwide Inpatient Sample to analyze risk of peripartum hysterectomy and associated severe maternal morbidity, mortality, surgical injury, reoperation, surgical-site complications, and mortality by maternal race and ethnicity. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, other, and unknown. Multivariable log-linear regression models including patient, clinical, and hospital risk factors were performed with adjusted risk ratios (aRRs) and 95% confidence intervals (CIs). RESULTS:Of 59,854,731 delivery hospitalizations, there were 45,369 peripartum hysterectomies (7.6 per thousand). Of these, 37.8% occurred among non-Hispanic white, 13.9% among non-Hispanic black, and 22.8% among Hispanic women. In adjusted analyses, non-Hispanic black (aRR: 1.21, 95% CI: 1.17-1.29) and Hispanic women (aRR: 1.25, 95% CI: 1.22-1.29) were at increased risk of hysterectomy compared with non-Hispanic white women. Risk for severe morbidity was increased for non-Hispanic black (aRR: 1.25, 95% CI: 1.19-1.33), but not for Hispanic (aRR: 1.02, 95% CI: 0.97-1.07) women. Between these three groups, risk for intraoperative complications was highest among non-Hispanic white women, risk for reoperation was highest among Hispanic women, and risk for surgical-site complications was highest among non-Hispanic black women. Evaluating maternal mortality, non-Hispanic black women (RR: 3.83, 95% CI: 2.65-5.53) and Hispanic women (RR: 2.49, 95% CI: 1.74-3.59) were at higher risk than non-Hispanic white women. CONCLUSION:Peripartum hysterectomy and related complications other than death differed modestly by race. In comparison, mortality differentials were large supporting that differential risk for death in the setting of this high-risk scenario may be an important cause of disparities. KEY POINTS:· Peripartum hysterectomy and related complications differed modestly by race.. · Mortality differentials in the setting of peripartum hysterectomy were large.. · Failure to rescue may be an important cause of peripartum hysterectomy disparities..

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/METHODS: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: < .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/CONCLUSIONS: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.