Faculty Bibliography

OBJECTIVE:This study aimed to assess risk for fetal acidemia, low Apgar scores, and hypoxic ischemic encephalopathy based on decision-to-incision time interval in the setting of emergency cesarean delivery. STUDY DESIGN:This unplanned secondary analysis of the Maternal-Fetal Medicine Units prospective observational cesarean registry dataset evaluated risk for hypoxic ischemic encephalopathy, umbilical cord pH ≤7.0, and Apgar score ≤4 at 5 minutes based on decision-to-incision time for emergency cesarean deliveries. Cesarean occurring for nonreassuring fetal heart rate monitoring, bleeding previa, nonreassuring antepartum testing, placental abruption, or cord prolapse was classified as emergent. Decision-to-incision time was categorized as <10 minutes, 10 to <20 minutes, 20 to <30 minutes, 30 to <50 minutes, or ≥50 minutes. As secondary outcomes umbilical cord pH ≤7.1, umbilical artery pH ≤7.0, and Apgar score ≤5 at 5 minutes were analyzed. RESULTS: = 0.04). Risk for secondary outcomes was also higher with shorter decision-to-incision intervals. CONCLUSION:Shorter decision-to-incision times were associated with increased risk for adverse outcomes in the setting of emergency cesarean. KEY POINTS:· Shorter intervals likely occur with higher risk cases.. · Shorter intervals were associated with higher neonatal risk.. · Shorter intervals were associated with low cord pH..

OBJECTIVE:To characterize trends in and risk factors for venous thromboembolism (VTE) during delivery hospitalizations in the United States. METHODS:The 2000-2018 National Inpatient Sample was used for this repeated cross-sectional analysis. Venous thromboembolism (including deep vein thrombosis [DVT] and pulmonary embolism) during delivery hospitalizations for women aged 15 to 54 years was determined by year. Temporal trends in VTE were characterized using joinpoint regression with estimates presented as the average annual percent change. Temporal trends in common VTE risk factors were also analyzed. The proportion of vaginal and cesarean deliveries by year that had VTE risk factors was determined, and average annual percent changes with 95% CIs were calculated. The relationship between risk factors and the likelihood of VTE events was determined with adjusted and unadjusted logistic regression models. RESULTS:Of 73,109,789 delivery hospitalizations, 48,546 VTE events occurred (6.6/10,000 deliveries), including 37,312 DVT diagnoses and 12,487 pulmonary embolism diagnoses. Rates increased significantly for vaginal (average annual percent change 2.5%, 95% CI 1.5-3.5%) but not for cesarean delivery hospitalizations (average annual percent change 0.3%, 95% CI -1.0 to 1.6%) over the study period. Pulmonary embolism increased for both vaginal delivery (average annual percent change 8.7%, 95% CI 6.0-11.5%) and cesarean delivery (average annual percent change 4.9%, 95% CI 3.6-6.2%). The proportion of cesarean deliveries with at least one VTE risk factor increased from 27.2% in 2000 to 43.6% in 2018 (average annual percent change 2.6%, 95% CI 2.2-3.1%) and for vaginal deliveries, from 17.7% to 31.4% (average annual percent change 3.4%, 95% CI 2.3-4.4%). The 5.9% of deliveries with at least two VTE risk factor diagnoses accounted for 25.4% of VTE diagnoses. Factors with the highest VTE risk included transfusion (adjusted odds ratio [aOR] 4.1, 95% CI 3.7-4.5), infection (aOR 5.8, 95% CI 5.3-6.3), history of VTE (aOR 7.2, 95% CI 6.2-8.4), and thrombophilias (aOR 9.6, 95% CI 8.5-11.0). CONCLUSION:Both risk factors for VTE and rate of pulmonary embolism increased over the study period. Deep vein thrombosis increased during vaginal delivery hospitalizations but not during cesarean delivery hospitalizations.

OBJECTIVE:To analyse trends, risk factors, and outcomes related to hypertensive disorders of pregnancy (HDP). DESIGN:Repeated cross-sectional. SETTING:US delivery hospitalisations. POPULATION:Delivery hospitalisations in the 2000-2018 National Inpatient Sample. METHODS:US hospital delivery hospitalisations with HDP were analysed. Several trends were analysed: (i) the proportion of deliveries by year with HDP, (ii) the proportion of deliveries with HDP risk factors and (iii) adverse outcomes associated with HDP including maternal stroke, acute renal failure and acute liver injury. Risk ratios were determined using regression models with HDP as the exposure of interest. MAIN OUTCOME MEASURES:Prevalence of HDP, risk factors for HDP and associated adverse outcomes. RESULTS:Of 73.1 million delivery hospitalisations, 7.7% had an associated diagnosis of HDP. Over the study period, HDP doubled from 6.0% of deliveries in 2000 to 12.0% in 2018. The proportion of deliveries with risk factors for HDP increased from 9.6% in 2000 to 24.6% in 2018. In adjusted models, HDP were associated with increased stroke (aRR [adjusted risk ratio] 15.9, 95% CI 14.8-17.1), acute renal failure (aRR 13.8, 95% CI 13.5-14.2) and acute liver injury (aRR 1.2, 95% CI 1.2-1.3). Among deliveries with HDP, acute renal failure and acute liver injury increased; in comparison, stroke decreased. CONCLUSION:Hypertensive disorders of pregnancy increased in the setting of risk factors for HDP becoming more common, whereas stroke decreased. TWEETABLE ABSTRACT:While hypertensive disorders of pregnancy increased from 2000 to 2018, stroke appears to be decreasing.

BACKGROUND/UNASSIGNED:Substance use disorders (SUDs) are increasing in the obstetric population, vary with demographic characteristics, and are associated with adverse pregnancy outcomes. Cannabis use disorder and opioid use disorder are two of the most common SUDs during pregnancy. OBJECTIVE/UNASSIGNED:This study had two objectives. The first objective was to assess trends in any SUD diagnosis during delivery hospitalizations from 2000 to 2018 by maternal age, ZIP code income quartile, and hospital location and teaching status. The second objective was to determine risk for adverse pregnancy outcomes during delivery hospitalizations specifically in the presence of cannabis and opioid use disorder diagnoses. STUDY DESIGN/UNASSIGNED:We conducted a serial cross-sectional analysis of the 2000-2018 National Inpatient Sample. Delivery hospitalizations to women aged 15-54 years with substance use disorder diagnoses were identified. SUD included (i) cannabis use disorder; (ii) opioid use disorder; (iii) alcohol use disorder; and (iv) other drug use disorder. We used joinpoint regression to estimate the average annual percent change (AAPC) in any substance use disorder diagnoses with 95% confidence intervals (CIs) by (i) ZIP code income quartile, (ii) hospital location and teaching status, and (iii) maternal age. We used unadjusted and adjusted log-linear regression to evaluate the relationship between cannabis use disorder and opioid use disorder several adverse maternal outcomes. We report unadjusted and adjusted risk ratios (aRRs) as measures of effect. RESULTS/UNASSIGNED:From 2000 to 2018, trends analyses broadly demonstrated increasing risk for SUD across demographic categories. In trends analyses stratified by ZIP code-income quartile, the proportion of deliveries with any SUD diagnosis increased across each income quartile with significant increases in the lowest income quartile (AAPC 4.6%, 95% CI 0.4%, 8.9%), second lowest quartile (AAPC 6.3%, 95% CI 5.3%, 7.4%), second highest quartile (AAPC 5.4%, 95% CI 4.1%, 6.8%), and highest quartile (AAPC 4.4%, 95% CI 2.1%, 6.8%). A larger increasing AAPC for SUD was present for deliveries in rural hospitals (AAPC 12.3%, 95% CI 9.8%, 14.9%) as compared to teaching (AAPC 5.7%, 95% CI 5.2%, 6.3%) and non-teaching urban hospitals (AAPC 7.0%, 95% CI 5.9%, 8.1%). By maternal age group, there was a significant larger AAPC for SUD for women aged 15-19 years (AAPC 8.5%, 95% CI 6.6%, 10.4%), 20-24 years (AAPC 9.0%, 95% CI 6.9%, 11.1%) and 25-29 years (AAPC 9.8%, 95% CI 9.1%, 10.6%) than women ≥30 years of age. Cannabis use disorder was associated with increased adjusted risk for preterm delivery (aRR 1.44, 95% CI 1.43, 1.45) and abruption and antepartum hemorrhage (aRR 1.77, 95% CI 1.75, 1.80). Opioid use disorder was associated with risk for non-transfusion severe maternal morbidity (aRR 1.73, 95% CI 1.67, 1.79), preterm delivery (aRR 1.75, 95% CI 1.74, 1.77), and abruption and antepartum hemorrhage (aRR 2.15, 95% CI 2.11, 2.19). CONCLUSION/UNASSIGNED:While substance use disorders are increasing in pregnancy across rural and urban settings, age groups, and income quartiles, several populations are associated with higher increased risks and trends. These findings support that SUDs are likely to continue to be of public health significance in diverse geographic and demographic settings.

PURPOSE/UNASSIGNED:To characterize temporal trends and outcomes of delivery hospitalization with maternal congenital heart disease (CHD). MATERIALS AND METHODS/UNASSIGNED: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/UNASSIGNED: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/UNASSIGNED: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.