Faculty Bibliography

BACKGROUND:Mental health conditions during delivery hospitalizations are not well characterized. OBJECTIVE:This study aimed to characterize the prevalence of maternal mental health condition diagnoses and associated risk during delivery hospitalizations in the United States. STUDY DESIGN:The 2000 to 2018 National Inpatient Sample was used for this repeated cross-sectional analysis. Delivery hospitalizations of women aged 15 to 54 years with and without mental health condition diagnoses, including depressive disorder, anxiety disorder, bipolar spectrum disorder, and schizophrenia spectrum disorder, were identified. Temporal trends in mental health condition diagnoses during delivery hospitalizations were determined using the National Cancer Institute's Joinpoint Regression Program to estimate the average annual percent change with 95% confidence intervals. The trends in chronic conditions associated with mental health condition diagnoses, including asthma, pregestational diabetes mellitus, chronic hypertension, obesity, and substance use, were analyzed. The association between mental health conditions and the following adverse outcomes was determined: (1) severe maternal morbidity, (2) preeclampsia or gestational hypertension, (3) preterm delivery, (4) postpartum hemorrhage, (5) cesarean delivery, and (6) maternal mortality. Regression models for each outcome were performed with unadjusted and adjusted risk ratios as measures of effects. RESULTS:Of 73,109,791 delivery hospitalizations, 2,316,963 (3.2%) had ≥1 associated mental health condition diagnosis. The proportion of delivery hospitalizations with a mental health condition increased from 0.6% in 2000 to 7.3% in 2018 (average annual percent change, 11.4%; 95% confidence interval, 10.3%-12.6%). Among deliveries in women with a mental health condition diagnosis, chronic health conditions, including asthma, pregestational diabetes mellitus, chronic hypertension, obesity, and substance use, increased from 14.9% in 2000 to 38.5% in 2018. Deliveries to women with a mental health condition diagnosis were associated with severe maternal morbidity (risk ratio, 1.88; 95% confidence interval, 1.86-1.90), preeclampsia and gestational hypertension (risk ratio, 1.59; 95% confidence interval, 1.58-1.60), preterm delivery (risk ratio, 1.35; 95% confidence interval, 1.35-1.36), postpartum hemorrhage (risk ratio, 1.37; 95% confidence interval, 1.36-1.38), cesarean delivery (risk ratio, 1.20; 95% confidence interval, 1.20-1.20), and maternal death (risk ratio, 1.31; 95% confidence interval, 1.12-1.56). The increased risk was retained in adjusted models. CONCLUSION:The proportion of delivery hospitalizations with mental health condition diagnoses increased significantly throughout the study period. Mental health condition diagnoses were associated with other underlying chronic health conditions and a modestly increased risk of a range of adverse outcomes. The findings suggested that mental health conditions are an important risk factor in adverse maternal outcomes.

OBJECTIVE:To characterize current trends and outcomes in pregnancies complicated by cystic fibrosis (CF) that resulted in delivery. METHODS:This repeated cross-sectional study used the U.S. National Inpatient Sample to identify delivery hospitalizations of patients with CF between 2000 and 2019. Trends in delivery hospitalizations of patients with CF were assessed using joinpoint regression to determine the average annual percent change (AAPC). The risk of adverse maternal and obstetric outcomes was compared between patients with and without CF using adjusted logistic regression models accounting for demographic, clinical, and hospital characteristics, with adjusted odds ratios (aORs) with 95% CIs as measures of association. The proportion of patients with CF and other chronic conditions such as pregestational diabetes was analyzed over time. RESULTS:From 2000 to 2019, the prevalence of CF at delivery increased from 2.1 to 10.4 per 100,000 deliveries (AAPC 6.7%, 95% CI 5.7-8.2%). The proportion of patients with CF and other chronic conditions increased from 18.0% to 37.3% (AAPC 3.1%, 95% CI 1.0-5.3%). Patients with CF were more likely to experience severe maternal morbidity (aOR 2.61, 95% CI 1.71-3.97), respiratory complications (aOR 17.45, 95% CI 11.85-25.68), venous thromboembolism (aOR 3.59, 95% CI 1.33-9.69), preterm delivery (aOR 2.15, 95% CI 1.79-2.59), abruption and antepartum hemorrhage (aOR 1.63, 95% CI 1.10-2.41), and gestational diabetes (aOR 2.47, 95% CI 2.47-3.70). CONCLUSION:Although still infrequent (approximately 1 in 10,000), deliveries complicated by CF increased approximately fivefold over the study period. The proportion of patients with CF and other chronic conditions is increasing. Patients with CF are at increased risk for a broad range of adverse outcomes.

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.

BACKGROUND/UNASSIGNED:Early postpartum discharges increased organically during the COVID-19 pandemic. It is not known if this 'natural experiment' of shorter postpartum hospital stays resulted in increased risk for postpartum readmissions and other acute postpartum care utilization such as emergency room encounters. OBJECTIVE/UNASSIGNED:The objectives of this study were to determine which clinical factors were associated with expedited postpartum discharge and whether the expedited postpartum discharge was associated with increased risk for acute postpartum care utilization. METHODS/UNASSIGNED:This retrospective cohort study evaluated birth hospitalizations at affiliated hospitals during two periods: (i) the apex of the 'first wave' of the COVID-19 pandemic in New York City (3/22/20 to 4/30/20) and (ii) a historical control period of one year earlier (3/22/19 to 4/30/19). Routine postpartum discharge was defined as ≥2 d after vaginal birth and ≥3 d after cesarean birth. Expedited discharge was defined as <2 d after vaginal birth and <3 d after cesarean birth. Acute postpartum care utilization was defined as any emergency room visit, obstetric triage visit, or postpartum readmission ≤6 weeks after birth hospitalization discharge. Demographic and clinical variables were compared based on routine versus expedited postpartum discharge. Unadjusted and adjusted logistic regression models were performed to analyze factors associated with (i) expedited discharge and (ii) acute postpartum care utilization. Unadjusted (ORs) and adjusted odds ratios (aORs) with 95% CIs were used as measures of association. Stratified analysis was performed restricted to patients with chronic hypertension, preeclampsia, and gestational hypertension. RESULTS/UNASSIGNED: < .01). For 2020, clinical factors significantly associated with a decreased likelihood of expedited discharge included hypertensive disorders of pregnancy (OR 0.40, 95% CI 0.27-0.60), chronic hypertension (OR 0.14, 95% CI 0.06-0.29), and COVID-19 infection (OR 0.51, 95% CI 0.34-0.77). Cesarean (OR 3.00, 95% CI 2.14-4.19) and term birth (OR 3.34, 95% CI 2.03, 5.49) were associated with an increased likelihood of expedited discharge. Most of the associations retained significance in adjusted models. Expedited compared to routine discharge was not associated with significantly different odds of acute postpartum care utilization for 2020 deliveries (5.4% versus 5.9%; OR 0.92, 95% CI 0.47-1.82). Medicaid insurance (OR 2.30, 95% CI 1.06-4.98) and HDP (OR 5.16, 95% CI: 2.60-10.26) were associated with a higher risk of acute postpartum care utilization and retained significance in adjusted analyses. In the stratified analysis restricted to women with hypertensive diagnoses, expedited discharge was associated with significantly increased risk for postpartum readmission (OR 6.09, 95% CI 2.14, 17.33) but not overall acute postpartum care utilization (OR 2.17, 95% CI 1.00, 4.74). CONCLUSION/UNASSIGNED:Expedited postpartum discharge was not associated with increased risk for acute postpartum care utilization. Among women with hypertensive diagnoses, expedited discharge was associated with a higher risk for readmission despite expedited discharge occurring less frequently.

Preterm birth is a leading cause of perinatal morbidity and mortality. Antenatal corticosteroid administration before preterm birth reduces the risks of perinatal death, respiratory morbidity, necrotizing enterocolitis, and intraventricular hemorrhage and reduces the costs of perinatal care. Antenatal corticosteroids are optimally effective when administered within 7 days before preterm birth. However, only 20% to 40% of early preterm infants receive antenatal corticosteroids within 7 days before birth, in part because it is difficult to predict the precise timing of preterm birth. Until 2020, The Joint Commission had a Perinatal Care quality metric measuring the rate of antenatal corticosteroid administration at any time before early preterm birth. This metric incentivized providers to use antenatal corticosteroids liberally. The Joint Commission retired the metric in 2020 after the rate reached more than 97% in The Joint Commission-accredited hospitals. However, the metric did not evaluate whether the timing of antenatal corticosteroid administration was optimal, that is, within 7 days of birth. A 2016 multistakeholder Cooperative Workshop recommended the development of a new quality metric to assess the rate of optimally timed antenatal corticosteroids among early preterm births. In this statement, we outline proposed specifications for such a metric and discuss potential uses, advantages, limitations, and barriers. Furthermore, we propose a balancing metric that tracks the percentage of patients treated with antenatal corticosteroids who ultimately give birth at term. We suggest that the use of these new metrics may incentivize more conservative antenatal corticosteroid timing, which could, in turn, lead to meaningfully improved outcomes for preterm neonates.

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.