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Objectives: The postpartum period represents an opportunity to intervene on the cardiovascular health of women who experience chronic hypertension in pregnancy or hypertensive disorders of pregnancy (HDP), including gestational hypertension, preeclampsia or eclampsia, and chronic hypertension with superimposed preeclampsia. This study sought to determine whether women who experience chronic hypertension or HDP access timely postpartum care compared to women with no documented hypertension. Methods: We used insurance claims data from the IBM MarketScan® Commercial Claims and Encounters Database. We included n=274,714 women 12-55 years old with a delivery hospitalization between 2017-2018 with continuous insurance enrollment from 3 months before the estimated start of pregnancy to 6 months after delivery discharge. Chronic hypertension and HDP were identified using International Classification of Diseases 10th Revision Clinical Modification codes. Distributions of time-to-event survival curves (time to first outpatient postpartum visit with a women’s health, primary care, or cardiology provider) were compared between the hypertension types using Kaplan-Meier estimators and logrank tests. Cox proportional hazards models were used to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CI). Time points of interest (3, 6, and 12 weeks) were consistent with visit benchmarks in traditional and updated postpartum care guidelines. Results: The prevalences of HDP, chronic, and no documented hypertension were 11.7%, 2.6%, and 85.7%, respectively. The proportions of women with a visit within 3 weeks of delivery discharge were 28.0%, 26.8%, and 15.8% for HDP, chronic, and no documented hypertension, respectively. By 12 weeks, the proportions increased to 59.6%, 61.3%, and 51.5%, respectively. Kaplan-Meier analyses indicated significant differences in utilization by hypertension type and interaction between hypertension type and time before and after 6 weeks. In adjusted Cox proportional hazards models, the utilization rate before 6 weeks among women with HDP was 1.42 times the rate for women with no documented hypertension (aHR=1.42, 95% CI: 1.40, 1.45). Women with chronic hypertension had similarly higher rates compared to women with no documented hypertension (aHR=1.29, 95% CI: 1.24, 1.35). There were no significant associations by hypertension type after 6 weeks. Conclusions: Women with HDP and chronic hypertension attend outpatient postpartum care visits faster than women with no documented hypertension. However, there were no significant associations by hypertension type after 6 weeks due to interaction with time before and after the traditional 6-week visit. Overall, utilization remains low in all groups. Addressing barriers to postpartum care attendance can ensure timely care for women at high risk for cardiovascular disease.

In this study, hospital discharge data from the 2016–2017 Healthcare Cost and Utilization Project were analyzed to describe national and, where data were available, state-specific prevalences of chronic hypertension and pregnancy-associated hypertension at delivery hospitalization. In 2016–2017, the prevalence of chronic hypertension was 216 per 10,000 delivery hospitalizations nationwide, ranging from 125 to 400 per 10,000 delivery hospitalizations in individual states. The prevalence of pregnancy-associated hypertension was 1021 per 10,000 delivery hospitalizations nationwide, ranging from 693 to 1382 per 10,000 delivery hospitalizations in individual states. The burden of hypertensive disorders in pregnancy remains high and varies considerably by jurisdiction.

Background: Cardiac arrest is a rare and sometimes fatal maternal complication. Severe hypertensive disorders of pregnancy (HDP) including preeclampsia with severe features, eclampsia, and Hemolysis, Elevated Liver enzymes, and Low Platelets (HELLP) syndrome are risk factors for maternal cardiac events. Surveillance on cardiac arrest and severe HDP during delivery is critical to informing evidence-based strategies to reduce pregnancy-related death. Methods: Using pooled data from the National Inpatient Sample from 2017-2019, we identified delivery hospitalizations among women aged 12-55 years. Delivery hospitalizations, cardiac arrest, and maternal medical conditions were identified using ICD-10-CM codes. Survival to hospital discharge was based on patient discharge disposition. Prevalence of cardiac arrest, severe HDP, and survival following cardiac arrest were calculated. We estimated the prevalence of severe HDP among delivery hospitalizations with cardiac arrest, cardiac arrest frequency among delivery hospitalizations with severe HDP, and survival to hospital discharge with co-occurring cardiac arrest and severe HDP. All estimates were weighted to account for complex sampling. Results: During 2017-2019, an estimated 10,921,784 delivery hospitalizations among which 1,465 cardiac arrests were identified. Overall cardiac arrest prevalence was 13.4 per 100,000 delivery hospitalizations (95% CI, 11.9-14.9). Of these, 1,005 (68.6% [95% CI, 63.2-74.0]) survived to hospital discharge. Overall prevalence of severe HDP was 2.7% (95% CI, 2.6-2.7) compared with 15.4% (95% CI 11.2-19.5) of delivery hospitalizations with cardiac arrest. Frequency of cardiac arrest per 100,000 delivery hospitalizations with severe HDP was 76.9 (95% CI, 54.6-99.2). Survival to hospital discharge with co-occurring cardiac arrest and severe HDP was 77.8% (95% CI, 65.6-89.9). Conclusion: Delivery hospitalizations affected by cardiac arrest are rare, and over two thirds survived to hospital discharge. Cardiac arrest disproportionately affected delivery hospitalizations among patients who had severe HDP.

Introduction: Hypertension is a leading risk factor for cardiovascular disease in the US. Approximately one in ten to one in six women of reproductive age (WRA; aged 18-44 years) have hypertension. Control of hypertension through lifestyle behaviors and anti-hypertensive medication can prevent complications across the life course. Characterizing the current use of anti-hypertensive medication among WRA by urban/rural status offers opportunities to inform public health action. Methods: Data from 59,407 WRA responding to the 2019 Behavioral Risk Factor Surveillance System was used to determine hypertension prevalence from 49 states (New Jersey did not meet data collection standards), District of Columbia, Guam, and Puerto Rico. Among the subset of 6,855 who self-reported hypertension, estimates of current anti-hypertensive medication use were calculated. Prevalence ratios were used to estimate the association between urban/rural status and self-reported use of anti-hypertensive medications, adjusting for age, race/ethnicity, education, and insurance status. Results: The estimated hypertension prevalence among WRA was 10.7% (95%CI:10.3%-11.1%) with 14.0% (95%CI:12.7%-15.5%) in rural and 10.4% (95%CI:10.0%-10.9%) in urban counties. An estimated 45.1% (95%CI:43.1%-47.2%) of WRA with hypertension reported currently using anti-hypertensive medication with estimates of 57.1% (95%CI:51.9%-62.1%) in rural and 44.0% (95%CI:41.9%-46.2%) in urban counties. WRA with hypertension living in rural counties were 1.29 times (95%CI:1.17-1.41) more likely to report currently using anti-hypertensive medication compared to those living in urban counties. Conclusion: Less than half of WRA with hypertension were currently using anti-hypertensive medication. Living in rural counties was associated with a higher frequency of use of anti-hypertensive medication. Ensuring appropriate blood pressure control through engagement in healthy lifestyle behaviors and appropriate use of medication when needed in WRA can improve cardiovascular health and reduce disparities.

This cross-sectional study investigates trends in death rates and proportion of deaths by pregnancy period among pregnant and postpartum individuals from 1994 to 2019.

Key Points Question What proportion of de novo severe maternal morbidity is diagnosed after delivery discharge, and what are the most common factors and maternal characteristics associated with severe maternal morbidity among women in the US? Findings In this cohort study of 2 667 325 women in the US with delivery hospitalizations between 2010 and 2014, 14% and 16% of severe maternal morbidity among those with commercial and Medicaid insurance, respectively, developed de novo within 6 weeks after delivery discharge. The most common factors and maternal characteristics associated with severe maternal morbidity after delivery were different than those identified at delivery. Meaning The study’s findings suggest that expanding the focus of severe maternal morbidity assessment to the postdelivery discharge period could improve understanding of severe maternal morbidity and may create opportunities to improve maternity care., Importance Previous efforts to examine severe maternal morbidity (SMM) in the US have focused on delivery hospitalizations. Little is known about de novo SMM that occurs after delivery discharge. Objective To investigate the incidence, timing, factors, and maternal characteristics associated with de novo SMM after delivery discharge among women in the US. Design, Setting, and Participants In this retrospective cohort study, data from the IBM MarketScan Multi-State Medicaid database and the IBM MarketScan Commercial Claims and Encounters database were used to construct a sample of women aged 15 to 44 years who delivered between January 1, 2010, and September 30, 2014. Severe maternal morbidity was reported by the timing of diagnosis, and the associated maternal characteristics were examined. Women in the Medicaid and commercial insurance sample were classified into 3 distinct outcome groups: (1) those without any SMM during the delivery hospitalization and the postdelivery period (reference group), (2) those who exhibited at least 1 factor associated with SMM during the delivery hospitalization, and (3) those who exhibited any factor associated with de novo SMM after delivery discharge (defined as SMM that was first diagnosed in the inpatient setting during the 6 weeks [or 42 days] after discharge from the delivery hospitalization, conditional on no factor associated with SMM being identified during delivery). Data were analyzed from February to July 2020. Exposures Timing of SMM diagnosis. Main Outcomes and Measures Women with SMM were identified using diagnosis and procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification for the 21 factors associated with SMM that were developed by the Centers for Disease Control and Prevention. Results A total of 2 667 325 women in the US with delivery hospitalizations between 2010 and 2014 were identified; of those, 809 377 women (30.3%) had Medicaid insurance (30.3%; mean [SD] age, 25.6 [5.5] years; 51.1% White), and 1 857 948 women (69.7%; mean [SD] age, 30.6 [5.4] years; 36.4% from the southern region of the US) had commercial insurance. Among those with Medicaid insurance, 17 584 women (2.2%) experienced SMM during the delivery hospitalization, and 3265 women (0.4%) experienced de novo SMM after delivery discharge. Among those with commercial insurance, 32 079 women (1.7%) experienced SMM during the delivery hospitalization, and 5275 women (0.3%) experienced de novo SMM after hospital discharge. A total of 5275 SMM cases (14.1%) and 3265 SMM cases (15.7%) among women with commercial and Medicaid insurance, respectively, developed de novo within 6 weeks after hospital discharge; of those, 3993 cases (75.7%) in the commercial insurance cohort and 2399 cases (73.5%) in the Medicaid cohort were identified in the first 2 weeks after discharge. The most common factors associated with SMM varied based on the timing of diagnosis. In the Medicaid population, non-Hispanic Black women (adjusted odds ratio [aOR], 1.53; 95% CI, 1.48-1.58), Hispanic women (aOR, 1.46; 95% CI, 1.37-1.57), and women of other races or ethnicities (aOR, 1.40; 95% CI, 1.33-1.47) had higher rates of SMM during delivery hospitalization than non-Hispanic White women; however, only the disparity between Black and White women (aOR, 1.69; 95% CI, 1.57-1.81) persisted into the postdischarge period. Conclusions and Relevance In this study, 14.1% of SMM cases in the Medicaid cohort and 15.7% of SMM cases in the commercial insurance cohort first occurred after the delivery hospitalization, with notable disparities in factors and maternal characteristics associated with the development of SMM. These findings suggest a need to expand the focus of SMM assessment to the postdelivery discharge period., This cohort study assesses the incidence, timing, factors, and maternal characteristics associated with de novo severe maternal morbidity after delivery discharge among women in the US.

Hypertension is one of the largest modifiable risk factors for cardiovascular disease in the United States, and when it occurs during pregnancy, it can lead to serious risks for both the mother and child. There is currently no nationwide or state surveillance system that specifically monitors hypertension among women of reproductive age (WRA). We reviewed hypertension information available in the Behavioral Risk Factor Surveillance System (BRFSS), National Health and Nutrition Examination Survey (NHANES), National Health Interview Survey (NHIS), and Pregnancy Risk Assessment and Monitoring System (PRAMS) health surveys, the Health care Cost and Utilization Project administrative data sets (National Inpatient Sample, State Inpatient Databases, Nationwide Emergency Department Sample, and State Emergency Department Database and the Nationwide Readmissions Database), and the National Vital Statistics System. BRFSS, NHIS, and NHANES and administrative data sets have the capacity to segment nonpregnant WRA from pregnant women. PRAMS collects information on hypertension before and during pregnancy only among women with a live birth. Detailed information on hypertension in the postpartum period is lacking in the data sources that we reviewed. Enhanced data collection may improve opportunities to conduct surveillance of hypertension among WRA.

Key Points Question Does the prevalence of chronic hypertension, hypertensive disorders of pregnancy, and eclampsia vary across the US by state? Findings In this cross-sectional study of 3 659 553 women who had live births in the US in 2017, the median odds of eclampsia were 2.4-fold higher if the same woman delivered in a state with a higher vs lower prevalence of eclampsia. The median odds ratios were substantially lower for chronic hypertension and hypertensive disorders of pregnancy. Meaning The findings of this study suggest that substantial variation among states exists in the prevalence of eclampsia across the US, despite controlling for multiple patient characteristics., Importance Hypertensive disorders of pregnancy are important causes of maternal and perinatal morbidity in the US. However, the extent of statewide variation in the prevalence of chronic hypertension, pregnancy-induced hypertension or preeclampsia, and eclampsia in the US remains unknown. Objective To examine the extent of statewide variation in the prevalence of chronic hypertension, hypertensive disorders of pregnancy (including pregnancy-induced hypertension or preeclampsia), and eclampsia in the US. Design, Setting, and Participants A cross-sectional study using 2017 US birth certificate data was conducted from September 1, 2019, to February 1, 2020. A population-based sample of 3 659 553 women with a live birth delivery was included. Main Outcomes and Measures State-specific prevalence of chronic hypertension, hypertensive disorders of pregnancy, and eclampsia was assessed using multilevel multivariable logistic regression, with the median odds ratio (MOR) to evaluate statewide variation. Results Of the 3 659 553 women, 185 932 women (5.1%) were younger than 20 years, 727 573 women (19.9%) were aged between 20 and 24 years, 1 069 647 women (29.2%) were aged between 25 and 29 years, 1 037 307 women (28.3%) were aged between 30 and 34 years, 523 607 women (14.3%) were aged between 35 and 39 years, and 115 487 women (3.2%) were 40 years or older. Most women had Medicaid (42.8%) or private insurance (49.4%). Hawaii had the lowest adjusted prevalence of chronic hypertension (1.0%; 95% CI, 0.9%-1.2%), and Alaska had the highest (3.4%; 95% CI, 3.0%-3.9%). Massachusetts had the lowest adjusted prevalence of hypertensive disorders of pregnancy (4.3%; 95% CI, 4.1%-4.6%), and Louisiana had the highest (9.3%; 95% CI, 8.9%-9.8%). Delaware had the lowest adjusted prevalence of eclampsia (0.03%; 95% CI, 0.01%-0.09%), and Hawaii had the highest (2.8%; 95% CI, 2.2%-3.4%). The degree of statewide variation was high for eclampsia (MOR, 2.36; 95% CI, 1.88-2.82), indicating that the median odds of eclampsia were 2.4-fold higher if the same woman delivered in a US state with a higher vs lower prevalence of eclampsia. Modest variation between states was observed for chronic hypertension (MOR, 1.27; 95% CI, 1.20-1.33) and hypertensive disorders of pregnancy (MOR, 1.17; 95% CI, 1.13-1.21). Conclusions and Relevance The findings of this study suggest that after accounting for patient-level and state-level variables, substantial state-level variation exists in the prevalence of eclampsia. These data can inform future public-health inquiries to identify reasons for the eclampsia variability., This cross-sectional study examines statewide variations in the prevalence of hypertensive disorders in pregnant women across the US.

To estimate the excess maternal health services utilization and direct maternal medical expenditures associated with hypertensive disorders during pregnancy and one year postpartum among women with private insurance in the United States.We used 2008-2014 IBM MarketScan® Commercial Databases to identify women aged 15-44 who had a pregnancy resulting in live birth during 1/1/09-12/31/13 and were continuously enrolled with non-capitated or partially capitated coverage from 12 months before pregnancy through 12 months after delivery. Hypertensive disorders identified by diagnosis codes were categorized into three mutually exclusive types: preeclampsia and eclampsia, chronic hypertension, and gestational hypertension. Multivariate negative binomial and generalized linear models were used to estimate service utilization and expenditures, respectively.Per person excess health services utilization and medical expenditures during pregnancy and one year postpartum associated with hypertensive disorders (in 2014 US dollars).Women with preeclampsia and eclampsia, chronic hypertension, and gestational hypertension had $9,389, $6,041, and $2,237 higher mean medical expenditures compared to women without hypertensive disorders ($20,252), respectively (ps 0.001). One-third (36%) of excess expenditure associated with hypertensive disorders during pregnancy was attributable to outpatient services.Hypertensive disorders during pregnancy were associated with significantly higher health services utilization and medical expenditures among privately insured women with hypertensive disorders. Medical expenditures varied by types of hypertensive disorders. Stakeholders can use this information to assess the potential economic benefits of interventions that prevent these conditions or their complications.

Background Limited data are available on the prospective relationship between beverage consumption and plasma lipid and lipoprotein concentrations. Two major sources of sugar in the US diet are sugar-sweetened beverages (SSBs) and 100% fruit juices. Low-calorie sweetened beverages are common replacements. Methods and Results Fasting plasma lipoprotein concentrations were measured in the FOS (Framingham Offspring Study) (1991-2014; N=3146) and Generation Three (2002-2001; N=3584) cohorts. Beverage intakes were estimated from food frequency questionnaires and grouped into 5 intake categories. Mixed-effect linear regression models were used to examine 4-year changes in lipoprotein measures, and Cox proportional hazard models were used to estimate hazard ratios for incident dyslipidemia, adjusting for potential confounding factors. We found that regular (1 serving per day) versus low (1 serving per month) SSB consumption was associated with a greater mean decrease in high-density lipoprotein cholesterol (β±standard error -1.6±0.4 mg/dL

This chapter reviews the historical development of indicators to identify severe maternal morbidity/maternal near miss (SMM/MNM), and their use for public health surveillance, research, and clinical audit. While there has been progress toward identifying standard definitions for SMM/MNM within countries, there remain inconsistencies in the definition of SMM/MNM indicators and their application between countries. Using these indicators to screen for events that then trigger a clinical audit may both under identify select SMM/MNM (false negative)and over identify select SMM/MNM (false positive). Thus, indicators which support the efficient identification of SMM/MNM for the purpose of facility-based clinical audits are still needed.

Introduction Diagnosis and control of chronic conditions have implications for women's health and are major contributing factors to maternal and infant morbidity and mortality. This study estimated the prevalence of hypertension and diabetes in non-pregnant women of reproductive age in the United States, the proportion who were unaware of their condition or whose condition was not controlled, and differences in the prevalence of these conditions by selected characteristics. Methods We used data from the 2011-2016 National Health and Nutrition Examination Survey to estimate overall prevalence of hypertension and diabetes among women of reproductive age (aged 20-44 y), the proportion who were unaware of having hypertension or diabetes, and the proportion whose diabetes or hypertension was not controlled. We used logistic regression models to calculate adjusted prevalence ratios to assess differences by selected characteristics. Results The estimated prevalence of hypertension was 9.3% overall. Among those with hypertension, 16.9% were unaware of their hypertension status and 40.7% had uncontrolled hypertension. Among women with diabetes, almost 30% had undiagnosed diabetes, and among those with diagnosed diabetes, the condition was not controlled in 51.5%. Conclusion This analysis improves our understanding of the prevalence of hypertension and diabetes among women of reproductive age and may facilitate opportunities to improve awareness and control of these conditions, reduce disparities in women's health, and improve birth outcomes.

In the U.S., deaths due to pulmonary embolism (PE) account for 9.2% of all pregnancy-related deaths or approximately 1.5 deaths per 100,000 live births. Maternal deaths and maternal morbidity due to PE are more common among women who deliver by cesarean section. In the past decade, the clinical community has increasingly adopted venous thromboembolism (VTE) guidelines and thromboprophylaxis recommendations for pregnant women. Although deep vein thrombosis rates have decreased during this time-period, PE rates have remained relatively unchanged in pregnancy hospitalizations and as a cause of maternal mortality. Changes in the health profile of women who become pregnant, particularly due to maternal age and co-morbidities, needs more attention to better understand the impact of VTE risk during pregnancy and the postpartum period.

BACKGROUND: Discharge diagnoses are used to track national trends and patterns of maternal morbidity. There are few data regarding the validity of the International Classification of Diseases (ICD) codes used for this purpose. The goal of our study was to try to better understand the validity of administrative data being used to monitor and assess trends in morbidity. METHODS: Hospital stay billing records were queried to identify all delivery admissions at the Massachusetts General Hospital for the time period 2001 to 2011 and the University of Michigan Health System for the time period 2005 to 2011. From this, we identified patients with ICD-9-Clinical Modification (CM) diagnosis and procedure codes indicative of severe maternal morbidity. Each patient was classified with 1 of 18 different medical/obstetric categories (conditions or procedures) based on the ICD-9-CM code that was recorded. Within each category, 20 patients from each institution were selected at random, and the corresponding medical charts were reviewed to determine whether the ICD-9-CM code was assigned correctly. The percentage of correct codes for each of 18 preselected clinical categories was calculated yielding a positive predictive value (PPV) and 99% confidence interval (CI). RESULTS: The overall number of correctly assigned ICD-9-CM codes, or PPV, was 218 of 255 (86%; CI, 79%–90%) and 154 of 188 (82%; CI, 74%–88%) at Massachusetts General Hospital and University of Michigan Health System, respectively (combined PPV, 372/443 [84%; CI, 79–88%]). Codes within 4 categories (Hysterectomy, Pulmonary edema, Disorders of fluid, electrolyte and acid–base balance, and Sepsis) had a 99% lower confidence limit ≥75%. Codes within 8 additional categories demonstrated a 99% lower confidence limit between 74% and 50% (Acute respiratory distress, Ventilation, Other complications of obstetric surgery, Disorders of coagulation, Cardiomonitoring, Acute renal failure, Thromboembolism, and Shock). Codes within 6 clinical categories demonstrated a 99% lower confidence limit

Objectives. We explored how changes in insurance coverage contributed to recent nationwide decreases in newborn circumcision. Methods. Hospital discharge data from the 2000–2010 Nationwide Inpatient Sample were analyzed to assess trends in circumcision incidence among male newborn birth hospitalizations covered by private insurance or Medicaid. We examined the impact of insurance coverage on circumcision incidence. Results. Overall, circumcision incidence decreased significantly from 61.3% in 2000 to 56.9% in 2010 in unadjusted analyses (P for trend = .008), but not in analyses adjusted for insurance status (P for trend = .46) and other predictors (P for trend = .55). Significant decreases were observed only in the South, where adjusted analyses revealed decreases in circumcision overall (P for trend = .007) and among hospitalizations with Medicaid (P for trend = .005) but not those with private insurance (P for trend = .13). Newborn male birth hospitalizations covered by Medicaid increased from 36.0% (2000) to 50.1% (2010; P for trend Conclusions. Shifts in insurance coverage, particularly toward Medicaid, likely contributed to decreases in newborn circumcision nationwide and in the South. Barriers to the availability of circumcision should be revisited, particularly for families who desire but have less financial access to the procedure.

A history of preterm birth (PTB) may be an important lifetime risk factor for cardiovascular disease (CVD) in women. We identified all peer-reviewed journal articles that met study criteria (English language, human studies, female, and adults ≥19 years old), that were found in the PubMed/MEDLINE databases, and that were published between Jan. 1, 1995, and Sept. 17, 2012. We summarized 10 studies that assessed the association between having a history of PTB and subsequent CVD morbidity or death. Compared with women who had term deliveries, women with any history of PTB had increased risk of CVD morbidity (variously defined; adjusted hazard ratio [aHR] ranged from 1.2e2.9; 2 studies), ischemic heart disease (aHR, 1.3e2.1; 3 studies), stroke (aHR, 1.7; 1 study), and atherosclerosis (aHR, 4.1; 1 study). Four of 5 studies that examined death showed that women with a history of PTB have twice the risk of CVD death compared with women who had term births. Two studies reported statistically significant higher risk of CVD—rerelated morbidity and death outcomes (variously defined) among women with —2 pregnancies that ended in PTBs compared with women who had at least 2 births but which ended in only 1 PTB. Future research is needed to understand the potential impact of enhanced monitoring of CVD risk factors in women with a history of PTB on risk of future CVD risk.

Objective Cardiomyopathy (CM) at delivery is increasing in prevalance. The objective of this study was to determine which medical conditions are attributable to this increasing prevalance. Design Population prevalence study from 2000 to 2009. Setting The Nationwide Inpatient Sample (NIS). Sample Pregnant women admitted for delivery were identified in the NIS for the years 2000–2009. Methods Temporal trends in pre-existing medical conditions and in medical and obstetric complications at delivery admissions were determined by linear regression. The change in the prevalence of CM among all pregnant women was compared with the change in the prevalance of CM among pregnant women without pre-existing conditions or complications. Main outcome measure Prevalence of CM. Results The prevalence of CM increased from 0.25 per 1000 deliveries in 2000 to 0.43 per 1000 deliveries in 2009 (P

OBJECTIVE To examine variability in diagnosed gestational diabetes mellitus (GDM) prevalence at delivery by race/ethnicity and state. RESEARCH DESIGN AND METHODS We used data from the Healthcare Cost and Utilization Project State Inpatient Databases for 23 states of the United States with available race/ethnicity data for 2008 to examine age-adjusted and race-adjusted rates of GDM by state. We used multilevel analysis to examine factors that explain the variability in GDM between states. RESULTS Age-adjusted and race-adjusted GDM rates (per 100 deliveries) varied widely between states, ranging from 3.47 in Utah to 7.15 in Rhode Island. Eighty-six percent of the variability in GDM between states was explained as follows: 14.7% by age; 11.8% by race/ethnicity; 5.9% by insurance; and 2.9% by interaction between race/ethnicity and insurance at the individual level; 17.6% by hospital level factors; 27.4% by the proportion of obese women in the state; 4.3% by the proportion of Hispanic women aged 15–44 years in the state; and 1.5% by the proportion of white non-Hispanic women aged 15–44 years in the state. CONCLUSIONS Our results suggest that GDM rates differ by state, with this variation attributable to differences in obesity at the population level (or “at the state level”), age, race/ethnicity, hospital, and insurance.

OBJECTIVES: To propose a new standard for monitoring severe maternal morbidity, update previous estimates of severe maternal morbidity during both delivery and postpartum hospitalizations, and estimate trends in these events in the United States between 1998 and 2009. METHODS: Delivery and postpartum hospitalizations were identified in the Nationwide Inpatient Sample for the period 1998–2009. International Classification of Diseases, 9 th Revision codes indicating severe complications were used to identify hospitalizations with severe maternal morbidity and related in-hospital mortality. Trends were reported using 2-year increments of data. RESULTS: Severe morbidity rates for delivery and postpartum hospitalizations for the 2008–2009 period were 129 and 29, respectively, for every 10,000 delivery hospitalizations. Compared with the 1998–1999 period, severe maternal morbidity increased by 75% and 114% for delivery and postpartum hospitalizations, respectively. We found increasing rates of blood transfusion, acute renal failure, shock, acute myocardial infarction, respiratory distress syndrome, aneurysms, and cardiac surgery during delivery hospitalizations. Moreover, during the study period, rates of postpartum hospitalization with 13 of the 25 severe complications examined more than doubled, and the overall mortality during postpartum hospitalizations increased by 66% (P,.05). CONCLUSIONS: Severe maternal morbidity currently affects approximately 52,000 women during their delivery hospitalizations and, based on current trends, this burden is expected to increase. Clinical review of identified cases of severe maternal morbidity can provide an opportunity to identify points of intervention for quality improvement in maternal care.

associated with early development of cardiovascular disease and risk for premature death. High sodium intake and overweight/ obesity are recognized as risk factors for hypertension in children. WHAT THIS STUDY ADDS: These results show that usual sodium intake was positively associated with systolic blood pressure and risk for pre-high blood pressure and high blood pressure among US children. The data indicate a synergistic interaction between sodium intake and weight status on risk for high blood pressure. abstract To assess the association between usual dietary sodium intake and blood pressure among US children and adolescents, over- all and by weight status. METHODS: Children and adolescents aged 8 to 18 years (n = 6235) who participated in NHANES 2003-2008 comprised the sample. Subjects' usual sodium intake was estimated by using multiple 24-hour dietary recalls. Linear or logistic regression was used to examine association between sodium intake and blood pressure or risk for pre-high blood pressure and high blood pressure (pre-HBP/HPB). RESULTS: Study subjects consumed an average of 3387 mg/day of sodium, and 37% were overweight/obese. Each 1000 mg per day sodium intake was associated with an increased SD score of 0.097 (95% confidence interval (CI) 0.006-0.188, ∼1.0 mmHg) in systolic blood pressure (SBP) among all subjects and 0.141 (95% CI: -0.010 to 0.298, ∼1.5 mm Hg) increase among overweight/obese subjects. Mean adjusted SBP increased progressively with sodium intake quartile, from 106.2 mm Hg (95% CI: 105.1-107.3) to 108.8 mm Hg (95% CI: 107.5-110.1) overall (P = .010) and from 109.0 mm Hg (95% CI: 107.2-110.8) to 112.8 mm Hg (95% CI: 110.7-114.9; P = .037) among those overweight/obese. Adjusted odds ratios comparing risk for pre-HBP/HPB among subjects in the highest versus lowest sodium intake quartile were 2.0 (95% CI: 0.95-4.1, P = .062) overall and 3.5 (95% CI: 1.3-9.2, P = .013) among those overweight/obese. Sodium intake and weight status appeared to have synergistic effects on risk for pre-HBP/HPB (relative excess risk for interaction = 0.29 (95% CI: 0.01-0.90, P , .05). CONCLUSIONS: Sodium intake is positively associated with SBP and risk for pre-HBP/HPB among US children and adolescents, and this as- sociation may be stronger among those who are overweight/obese. Pediatrics 2012;130:611-619

The American Heart Association (AHA), Institute of Medicine (IOM), and US Departments of Health and Human Services and Agriculture (USDA) Dietary Guidelines for Americans all recommend that Americans limit sodium intake and choose foods that contain potassium to decrease the risk of hypertension and other adverse health outcomes.We estimated the distributions of usual daily sodium and potassium intakes by sociodemographic and health characteristics relative to current recommendations.We used 24-h dietary recalls and other data from 12,581 adults aged ≥20 y who participated in NHANES in 2003-2008. Estimates of sodium and potassium intakes were adjusted for within-individual day-to-day variation by using measurement error models. SEs and 95% CIs were assessed by using jackknife replicate weights.Overall, 99.4% (95% CI: 99.3%, 99.5%) of US adults consumed more sodium daily than recommended by the AHA (1500 mg), and 90.7% (89.6%, 91.8%) consumed more than the IOM Tolerable Upper Intake Level (2300 mg). In US adults who are recommended by the Dietary Guidelines to further reduce sodium intake to 1500 mg/d (ie, African Americans aged ≥51 y or persons with hypertension, diabetes, or chronic kidney disease), 98.8% (98.4%, 99.2%) overall consumed1500 mg/d, and 60.4% consumed3000 mg/d-more than double the recommendation. Overall,2% of US adults and ~5% of US men consumed ≥4700 mg K/d (ie, met recommendations for potassium).Regardless of recommendations or sociodemographic or health characteristics, the vast majority of US adults consume too much sodium and too little potassium.

Objective The role of occupation in the management of cardiovascular risk factors including hypertension is not well known. Methods We analyzed the 1999-2004 National Health and Nutrition Examination Survey data of 6928 workers aged 20 years or older from 40 occupational groups. Hypertension was defined as measured blood pressure of 140/90 mm Hg or greater or self-reported use of antihypertensive medication, treatment as use of antihypertensive medication, awareness as ever being told by a doctor about having hypertension, and control as having blood pressure of less than 140/90 mm Hg among treated participants. Results Protective service workers ranked among the lowest in awareness (50.6%), treatment (79.3%), and control (47.7%) and had lower odds of hypertension control and treatment compared with executive/administrative/managerial workers, adjusting for sociodemographic, body-weight, smoking, and alcohol. Conclusions Protective service workers may benefit the most from worksite hypertension management programs.

Objective To assess the prevalence and risk factors of cardiovascular disease (CVD) among younger women by pregnancy history. Methods Cross-sectional study using 1999 to 2006 National Health and Nutrition Examination Survey including women aged 20 to 64 years who had delivered at least one infant (n = 4820). Women self-reported pregnancy history and a clinician diagnosed CVD; CVD risk factors included hypertension (mean systolic blood pressure [BP] ≥140 mm Hg or mean diastolic BP ≥90 mm Hg, or currently treated), high cholesterol (total cholesterol ≥240 mg/dL or currently treated), diabetes (self-report or hemoglobin A1c ≥6.5), and smoking (self-report or cotinine-verified). Multivariable logistic regression was used to assess the association between pregnancy history and CVD. Results Of the women we studied, 4.6% had CVD; 3.1% had delivered a term low-birth-weight infant (TLBWI). Women with a history of TLBWI had an adjusted odds ratio (AOR) of 2.07 (95% confidence intervals [CI] 1.08 to 3.99) for CVD compared with women without a history of LBWI. Adjustment for hypertension and high cholesterol mildly attenuated the association (AOR 1.85, 95% CI 0.89 to 3.83). Among women without CVD (n = 4555), 23.1% with a history of TLBWI had two risk factors compared with 14.0% of those without a history of LBWI (p = 0.0016). Conclusion Women with a history of TLBWI should be informed of a possible increased risk of CVD and encouraged to receive screenings as recommended.

OBJECTIVE: Overweight and obesity during adolescence are associated with an increased risk for cardiovascular disease (CVD) risk factors. The objective of this study was to examine the recent trends in the prevalence of selected biological CVD risk factors and the prevalence of these risk factors by overweight/obesity status among US adolescents. METHODS: The NHANES is a cross-sectional, stratified, multistage probability sample survey of the US civilian, noninstitutionalized population. The study sample included 3383 participants aged 12 to 19 years from the 1999 through 2008 NHANES. RESULTS: Among the US adolescents aged 12 to 19 years, the overall prevalence was 14% for prehypertension/hypertension, 22% for borderline-high/high low-density lipoprotein cholesterol, 6% for low high-density lipoprotein cholesterol ( CONCLUSIONS: The results of this national study indicate that US adolescents carry a substantial burden of CVD risk factors, especially those youth who are overweight or obese.

This paper reviews how epidemiological studies during the last 5 years have advanced our knowledge in addressing the global stroke epidemic. The specific objectives were to review the current evidence supporting management of ten major modifiable risk factors for prevention of stroke: hypertension, current smoking, diabetes, obesity, poor diet, physical inactivity, atrial fibrillation, excessive alcohol consumption, abnormal lipid profile and psychosocial stress/depression.

J Clin Hypertens (Greenwich). 2011;13:739–743. ©2011 Wiley Periodicals, Inc. Sleep is a contributing factor to optimal health and vitality. However, to date, no national study has evaluated the simultaneous relationship between sleep disorders, quality, and duration with hypertension. Using data from National Health and Nutrition Examination Survey (NHANES) (2005 to 2008), hypertension was defined by current use of antihypertensive medication or systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg. Self-reported sleep disorders and duration were categorized from a single household interview question, and sleep quality was determined from several questions on sleeping habits. The prevalence of hypertension was 30.2% and 7.5%, and 33.0% and 52.1% reported having sleep disorders, short sleep, and poor sleep, respectively. After adjustment for demographic characteristics and comorbidities, having sleep disorders only was not significantly associated with hypertension (odds ratio [OR], 1.65; 95% confidence interval [CI], 0.73−3.77). However, this association was modified by sleep duration: significant associations were observed among adults with concurrent sleep disorders and short sleep (OR, 2.30; 95% CI, 1.49−3.56) and with sleep disorders, short sleep, and poor sleep (OR, 1.84; 95% CI, 1.13−2.98). These findings indicate an association between a combination of sleep problems and hypertension, but prospective studies are needed to understand the complex interplay between them.

Background: We evaluated the influence of type and timing of prophylaxis on perinatal HIV transmission in St. Petersburg, Russia. Methods: We linked surveillance data for 1498 HIV-infected mothers delivering from 2004 to 2007 with polymerase chain reaction data for 1159 infants to determine predictors of transmission. Results: The overall perinatal transmission rate was 6.3% [73 of 1159, 95% confidence interval (CI) 4.9% to 7.7%]. Among the 12.8% (n = 149) of mother―infant pairs receiving full course (antenatal, intrapartum, postnatal) dual/triple antiretroviral prophylaxis, the transmission rate was 2.7%. Among the 1010 receiving less complete regimens (full course zidovudine, single-dose nevirapine, or incomplete), transmission ranged from 4.1% to 12.2%. Among the 28.9% (330) of mothers initiating antiretroviral drugs ≤20 weeks gestation, perinatal transmission was 1.8%, compared with 4.0%, 8.6%, and 11.3% for those initiating antiretrovirals at 21―28 weeks, 29―42 weeks, or during labor and delivery, respectively (P for trend

PURPOSE Previous studies have reported low rates of screening for high cholesterol levels among young adults in the United States. Although recommendations for screening young adults without risk factors for coronary heart disease (CHD) differ, all guidelines recommend screening adults with CHD, CHD equivalents, or 1 or more CHD risk factors. This study examined national prevalence of CHD risk factors and compliance with the cholesterol screening guidelines among young adults. METHODS National estimates were obtained using results for 2,587 young adults (men aged 20 to 35 years; women aged 20 to 45 years) from the 1999–2006 National Health and Nutrition Examination Surveys. We defined high low-density lipoprotein cholesterol (LDL-C) as levels higher than the goal specific for each CHD risk category outlined in the National Cholesterol Education Program Adult Treatment Panel III guidelines. RESULTS About 59% of young adults had CHD or CHD equivalents, or 1 or more of the following CHD risk factors: family history of early CHD, smoking, hypertension, or obesity. In our study, the overall screening rate in this population was less than 50%. Moreover, no significant difference in screening rates between young adults with no risk factors and their counterparts with 1 or more risk factors was found even after adjustment for sociodemographic and health care factors. Approximately 65% of young adults with CHD or CHD equivalents, 26% of young adults with 2 or more risk factors, 12% of young adults with 1 risk factor, and 7% with no risk factor had a high level of LDL-C. CONCLUSIONS CHD risk factors are common in young adults but do not appear to alter screening rates. Improvement of risk assessment and management for cardiovascular disease among young adults is warranted.

OBJECTIVES:To estimate the rate of pregnancy hospitalizations for women with two groups of myocardial disorders, cardiomyopathy and other myocardial disorders, and report the rate of severe obstetric complications among these hospitalizations in delivery and postpartum periods.METHODS:We performed a

OBJECTIVE To examine trends in the prevalence of diabetes among delivery hospitalizations in the U.S. and to describe the characteristics of these hospitalizations. RESEARCH DESIGN AND METHODS Hospital discharge data from 1994 through 2004 were obtained from the Nationwide Inpatient Sample. Diagnosis codes were selected for gestational diabetes mellitus (GDM), type 1 diabetes, type 2 diabetes, and unspecified diabetes. Rates of delivery hospitalization with diabetes were calculated per 100 deliveries. RESULTS Overall, an estimated 1,863,746 hospital delivery discharges contained a diabetes diagnosis, corresponding to a rate of 4.3 per 100 deliveries over the 11-year period. GDM accounted for the largest proportion of delivery hospitalizations with diabetes (84.7%), followed by type 1 (7%), type 2 (4.7%), and unspecified diabetes (3.6%). From 1994 to 2004, the rates for all diabetes, GDM, type 1 diabetes, and type 2 diabetes significantly increased overall and within each age-group (15–24, 25–34, and ≥35 years) (P < 0.05). The largest percent increase for all ages was among type 2 diabetes (367%). By age-group, the greatest percent increases for each diabetes type were among the two younger groups. Significant predictors of diabetes at delivery included age ≥35 years vs. 15–24 years (odds ratio 4.80 [95% CI 4.72–4.89]), urban versus rural location (1.14 [1.11–1.17]), and Medicaid/Medicare versus other payment sources (1.29 [1.26–1.32]). CONCLUSIONS Given the increasing prevalence of diabetes among delivery hospitalizations, particularly among younger women, it will be important to monitor trends in the pregnant population and target strategies to minimize risk for maternal/fetal complications.

The purpose of this study was to describe trends in the prevalence of eating disorders among delivery hospitalizations in the United States from 1994 to 2004 and to compare hospital, demographic, and obstetrical outcomes among women with and without eating disorders.Hospital discharge data for 1994 to 2004 from the Nationwide Inpatient Sample (NIS) were used to assess the relationship between eating disorders (anorexia nervosa and bulimia nervosa) and obstetrical complications. Analyses were limited to delivery-related hospitalizations.There were an estimated 1,668 delivery hospitalizations with an eating disorder diagnosis in the United States in the 11-year period, resulting in an overall rate of 0.39 per 10,000 deliveries. After adjustment for hospital and demographic characteristics, delivery hospitalizations with an eating disorder were significantly more likely than those without an eating disorder to have fetal growth restriction (odds ratio [OR] 9.08, 95% confidence interval [CI] 6.45-12.77), preterm labor (OR 2.78, 95% CI 2.10-3.69), anemia (OR 1.73, 95% CI 1.25-2.38), genitourinary tract infections (OR 1.66, 95% CI 1.03-2.68), and labor induction (OR 1.32, 95% CI 1.01-1.73).Although the prevalence of eating disorders among delivery hospitalizations is lower than in the general population, the fact that women with eating disorders are at increased risk of adverse pregnancy outcomes highlights the importance of screening for and appropriate clinical care of eating disorders in pregnancy.

Objectives The accuracy of maternal morbidity estimates from hospital discharge data may be influenced by incomplete identification of deliveries. In maternal/infant health studies, obstetric deliveries are often identified only by the maternal outcome of delivery code (International Classification of Diseases code = V27). We developed an enhanced delivery identification method based on additional delivery-related codes and compared the performance of the enhanced method with the V27 method in identifying estimates of deliveries as well as estimates of maternal morbidity. Methods The enhanced and standard V27 methods for identifying deliveries were applied to data from the 1998–2004 Healthcare Cost and Utilization Project Nationwide Inpatient Sample, an annual nationwide representative survey of U.S. hospitalizations. Odds ratios (ORs) and 95% confidence intervals (CIs) from logistic regression were used to examine predictors of deliveries not identified using the V27 method. Results The enhanced method identified 958,868 (3.4%) more deliveries than the 27,128,539 identified using the V27 code alone. Severe complications including major puerperal infections (OR = 3.1, 95% CI 2.8–3.4), hysterectomy (OR = 6.0, 95% CI 5.3–6.8), sepsis (OR = 11.9, 95% CI 10.3–13.6) and respiratory distress syndrome (OR = 16.6, 95% CI 14.4–19.2) were strongly associated with deliveries not identified by the V27 method. Nationwide prevalence rates of severe maternal complications were underestimated with the V27 method compared to the enhanced method, ranging from 9% underestimation for major puerperal infections to 40% underestimation for respiratory distress syndrome. Conclusion Deliveries with severe obstetric complications may be more likely to be missed using the V27 code. Researchers should be aware that selecting deliveries from hospital stay records by V27 codes alone may affect the accuracy of their findings.

Background— Hospitalizations for pregnancy-related stroke are rare but increasing. Hemorrhagic stroke (HS), ie, subarachnoid hemorrhage and intracerebral hemorrhage, is more common than ischemic stroke in pregnant versus nonpregnant women, reflecting different phenotypes or risk factors. We compared stroke risk factors and outcomes in pregnant versus nonpregnant HS in the Get With The Guidelines-Stroke Registry. Methods and Results— Using medical history or International Classification of Diseases - Ninth Revision codes, we identified 330 pregnant and 10 562 nonpregnant female patients aged 18 to 44 years with HS in Get With The Guidelines-Stroke (2008–2014). Differences in patient and care characteristics were compared by χ 2 or Fisher exact test (categorical variables) or Wilcoxon rank-sum (continuous variables) tests. Conditional logistic regression assessed the association of pregnancy with outcomes conditional on categorical age and further adjusted for patient and hospital characteristics. Pregnant versus nonpregnant HS patients were younger with fewer pre-existing stroke risk factors and medications. Pregnant versus nonpregnant subarachnoid hemorrhage patients were less impaired at arrival, and less than half met blood pressure criteria for severe preeclampsia. In-hospital mortality was lower in pregnant versus nonpregnant HS patients: adjusted odds ratios (95% CI) for subarachnoid hemorrhage 0.17 (0.06–0.45) and intracerebral hemorrhage 0.57 (0.34–0.94). Pregnant subarachnoid hemorrhage patients also had a higher likelihood of home discharge (2.60 [1.67–4.06]) and independent ambulation at discharge (2.40 [1.56–3.70]). Conclusions— Pregnant HS patients are younger and have fewer risk factors than their nonpregnant counterparts, and risk-adjusted in-hospital mortality is lower. Our findings suggest possible differences in underlying disease pathophysiology and challenges to identifying at-risk patients.

To estimate nationwide trends in the prevalence of maternal congenital heart disease (CHD) and determine whether women with CHD are more likely than women without maternal CHD to have medical and obstetric complications.The 2000-2010 Nationwide Inpatient Sample was queried for International Classification of Diseases, 9th Revision, Clinical Modification codes to identify delivery hospitalizations of women with and without CHD. Trends in the prevalence of CHD were determined and then rates of complications were reported for CHD per 10,000 delivery hospitalizations. For Nationwide Inpatient Sample 2008-2010, logistic regression was used to examine associations between CHD and complications.From 2000 to 2010, there was a significant linear increase in the prevalence of CHD from 6.4 to 9.0 per 10,000 delivery hospitalizations (P.001). Multivariable logistic regression demonstrated that all selected medical complications, including mortality (17.8 compared with 0.7/10,000 deliveries, adjusted odds ratio [OR] 22.10, 95% confidence interval [CI] 13.96-34.97), mechanical ventilation (91.9 compared with 6.9/10,000, adjusted OR 9.94, 95% CI 7.99-12.37), and a composite cardiovascular outcome (614 compared with 34.3/10,000, adjusted OR 10.54, 95% CI 9.55-11.64) were more likely to occur among delivery hospitalizations with maternal CHD than without. Obstetric complications were also common among women with CHD. Delivery hospitalizations with maternal CHD that also included codes for pulmonary circulatory disorders had higher rates of medical complications compared with hospitalizations with maternal CHD without pulmonary circulatory disorders.The number of delivery hospitalizations with maternal CHD in the United States is increasing, and although we were not able to determine whether correction of the cardiac lesion affected outcomes, these hospitalizations have a high burden of medical and obstetric complications.II.

Background: Stroke accounts for 14% of maternal deaths. Our knowledge of the risk factors and etiologies of pregnancy-related stroke (PRS) is limited, as most data are derived from small, single center series or large, administrative datasets lacking clinical detail. We sought to describe the patient and hospital characteristics of PRS by analyzing the Get with the Guidelines (GWTG) Stroke Registry. Methods: All female patients aged 18-44 entered into GWTG from 2008-2013 with PRS were ascertained by medical history of pregnancy (i.e. pregnant or Results: We identified 46043 patients with stroke from 1554 sites, of whom 668 (1.5%) had PRS. Ischemic stroke (IS) occurred in 338 (51%), intracerebral hemorrhage (ICH) in 178 (27%) and subarachnoid hemorrhage (SAH) in 152 (23%). Many patient and hospital characteristics differed significantly by stroke subtype (Table). Hypertension, smoking and pre-stroke therapy with antithrombotics or antihypertensives were common; 7.4% of IS were recurrent. About 86% of all strokes did not occur in a healthcare setting and only 27% of patients arrived by EMS. Median initial blood pressure (BP) was higher in HS (ICH and SAH) than in IS, and half of all patients had initial BP below the threshold for pre-eclampsia (140/90 mmHg). HS patients were more often treated at larger, academic hospitals. Conclusions: PRS constituted 1.5% of all strokes aged 18-44 in a large contemporary stroke registry and 50% were HS. Most PRS occurred out of hospital, and half of all cases presented with normal BP levels. Further research is needed to better define PRS etiology.

The purpose of this study was to examine cesarean delivery morbidity and its predictors in the United States.We used 2000-2011 Nationwide Inpatient Sample data to identify cesarean deliveries and records with 12 potential cesarean delivery complications, including placenta accreta. We estimated cesarean delivery morbidity rates and rate changes from 2000-2011, and fitted Poisson regression models to assess the relative incidence of morbidity among repeat vs primary cesarean deliveries and explore its predictors.From 2000-2011, 76 in 1000 cesarean deliveries (97 in 1000 primary and 48 in 1000 repeat cesarean deliveries) were accompanied by ≥1 of 12 complications. The unadjusted composite cesarean delivery morbidity rate increased by 3.6% only among women with a primary cesarean delivery (P.001); the unadjusted rate of placenta accreta increased by 30.8% only among women with a repeat cesarean deliveries (P = .025). The adjusted rate of overall composite cesarean delivery morbidity decreased by 1% annually from 2000-2011 (P.001). Compared with women with a primary cesarean delivery, those women who underwent a repeat cesarean delivery were one-half as likely (incidence rate ratio, 0.50; 95% CI, 0.49-0.50) to experience a complication, but 2.13 (95% CI, 1.98-2.29) times more likely to have a placenta accreta diagnosis. Both cesarean delivery morbidity and placenta accreta were positively associated with age30 years, non-Hispanic black race/ethnicity, the presence of a chronic medical condition, and delivery in urban, teaching, or larger hospitals.Overall, cesarean delivery morbidity declined modestly from 2000-2011, but placenta accreta became an increasingly important contributor to repeat cesarean delivery morbidity. Clinicians should maintain a high index of suspicion for abnormal placentation and make adequate preparations for patients who need cesarean deliveries.

Background: The objective of this analysis was to evaluate the frequency, distribution of potential etiologies, and survival rates of maternal cardiopulmonary arrest during the hospitalization for delivery in the United States. Methods: By using data from the Nationwide Inpatient Sample during the years 1998 through 2011, the authors obtained weighted estimates of the number of U.S. hospitalizations for delivery complicated by maternal cardiac arrest. Clinical and demographic risk factors, potential etiologies, and outcomes were identified and compared in women with and without cardiac arrest. The authors tested for temporal trends in the occurrence and survival associated with maternal arrest. Results: Cardiac arrest complicated 1 in 12,000 or 8.5 per 100,000 hospitalizations for delivery (99% CI, 7.7 to 9.3 per 100,000). The most common potential etiologies of arrest included hemorrhage, heart failure, amniotic fluid embolism, and sepsis. Among patients with cardiac arrest, 58.9% of patients (99% CI, 54.8 to 63.0%) survived to hospital discharge. Conclusions: Approximately 1 in 12,000 hospitalizations for delivery is complicated by cardiac arrest, most frequently due to hemorrhage, heart failure, amniotic fluid embolism, or sepsis. Survival depends on the underlying etiology of arrest.

Objective We sought to explore how racial/ethnic minority-serving hospitals perform on 15 delivery-related indicators, and examine whether indicators vary by race/ethnicity within the same type of hospitals. Study Design We used 2008 through 2011 linked State Inpatient Database and American Hospital Association data from 7 states, and designated hospitals with >50% of deliveries to non-Hispanic white, non-Hispanic black, and Hispanic women as white-, black-, and Hispanic-serving, respectively. We calculated indicator rates per 1000 deliveries by hospital type and, separately, for non-Hispanic white, non-Hispanic black, and Hispanic women within each hospital type. We fitted multivariate Poisson regression models to examine associations between delivery-related indicators and patient and hospital characteristics by hospital type. Results White-serving hospitals offer obstetric care to an older and wealthier population than black- or Hispanic-serving hospitals. Rates of the most prevalent indicators examined (complicated vaginal delivery, complicated cesarean delivery, obstetric trauma) were lowest in Hispanic-serving hospitals. Generally, indicator rates were similar in Hispanic- and white-serving hospitals. Black-serving hospitals performed worse than other hospitals on 12 of 15 indicators. Indicator rates varied greatly by race/ethnicity in white- and Hispanic-serving hospitals, with non-Hispanic blacks having 1.19-3.27 and 1.15-2.68 times higher rates than non-Hispanic whites, respectively, for 11 of 15 indicators. Conversely, there were few indicator rate differences by race/ethnicity in black-serving hospitals, suggesting an overall lower performance of these hospitals compared to white- and Hispanic-serving hospitals. Conclusion We found considerable differences in delivery-related indicators by hospital type and patients’ race/ethnicity. Obstetric care quality measures are needed to track racial/ethnic disparities at the facility and population levels.

To evaluate trends and associations of hypertensive disorders of pregnancy with stroke risk and test the hypothesis that hypertensive disorders of pregnancy-associated stroke results in higher rates of stroke-related complications than pregnancy-associated stroke without hypertensive disorders.A cross-sectional study was performed using 81,983,216 pregnancy hospitalizations from the 1994-2011 Nationwide Inpatient Sample. Rates of stroke hospitalizations with and without these hypertensive disorders were reported per 10,000 pregnancy hospitalizations. Using logistic regression, adjusted odds ratios (OR) with 95% confidence intervals were obtained.Between 1994-1995 and 2010-2011, the nationwide rate of stroke with hypertensive disorders of pregnancy increased from 0.8 to 1.6 per 10,000 pregnancy hospitalizations (103%), whereas the rate without these disorders increased from 2.2 to 3.2 per 10,000 pregnancy hospitalizations (47%). Women with hypertensive disorders of pregnancy were 5.2 times more likely to have a stroke than those without. Having traditional stroke risk factors (eg, congenital heart disease, atrial fibrillation, sickle cell anemia, congenital coagulation defects) substantially increased the stroke risk among hypertensive disorders of pregnancy hospitalizations: from adjusted OR 2.68 for congenital coagulation defects to adjusted OR 13.1 for congenital heart disease. Stroke-related complications were increased in stroke with hypertensive disorders of pregnancy compared with without (from adjusted OR 1.23 for nonroutine discharge to adjusted OR 1.93 for mechanical ventilation).Having traditional stroke risk factors substantially increased the stroke risk among hypertensive disorders of pregnancy hospitalizations. Stroke with hypertensive disorders in pregnancy had two distinctive characteristics: a greater increase in frequency since the mid-1990s and significantly higher stroke-related complication rates.III.

The duration and exclusivity of breastfeeding in infancy have been inversely associated with future cardiometabolic risk. We investigated the effects of an experimental intervention to promote increased duration of exclusive breastfeeding on cardiometabolic risk factors in childhood.We followed-up children in the Promotion of Breastfeeding Intervention Trial, a cluster-randomized trial of a breastfeeding promotion intervention based on the World Health Organization/United Nations Children's Fund Baby-Friendly Hospital Initiative. In 1996 to 1997, 17 046 breastfeeding mother-infant pairs were enrolled from 31 Belarusian maternity hospitals and affiliated polyclinics (16 intervention versus 15 control sites); 13 879 (81.4%) children were followed up at 11.5 years, with 13 616 (79.9%) who had fasted and did not have diabetes mellitus. The outcomes were blood pressure; fasting insulin, adiponectin, glucose, and apolipoprotein A1; and the presence of metabolic syndrome. Analysis was by intention to treat, accounting for clustering within hospitals/clinics. The intervention substantially increased breastfeeding duration and exclusivity in comparison with the control arm (43% versus 6% and 7.9% versus 0.6% exclusively breastfed at 3 and 6 months, respectively). Cluster-adjusted mean differences at 11.5 years between experimental versus control groups were as follows: 1.0 mm Hg (95% confidence interval, -1.1 to 3.1) for systolic and 0.8 mm Hg (-0.6 to 2.3) for diastolic blood pressure; -0.1 mmol/L (-0.2 to 0.1) for glucose; 8% (-3% to 34%) for insulin; -0.3 μg/mL (-1.5 to 0.9) for adiponectin; and 0.0 g/L (-0.1 to 0.1) for apolipoprotein A1. The cluster-adjusted odds ratio for metabolic syndrome, comparing experimental versus control groups, was 1.21 (0.85 to 1.72).An intervention to improve breastfeeding duration and exclusivity among healthy term infants did not influence cardiometabolic risk factors in childhood.Current Controlled Trials: ISRCTN37687716 (http://www.controlled-trials.com/ISRCTN37687716). URL: http://clinicaltrials.gov. Unique identifier: NCT01561612.

Objective To define the frequency, risk factors, and outcomes of massive transfusion in obstetrics. Methods The State Inpatient Dataset for New York (1998-2007) was used to identify all delivery hospitalizations for hospitals that reported at least one delivery-related transfusion per year. Multivariable logistic regression analysis was performed to examine the relationship between maternal age, race, and relevant clinical variables and the risk of massive blood transfusion defined as 10 or more units of blood recorded. Results Massive blood transfusion complicated 6 of every 10,000 deliveries with cases observed even in the smallest facilities. Risk factors with the strongest independent associations with massive blood transfusion included abnormal placentation (1.6/10,000 deliveries, adjusted odds ratio [OR] 18.5, 95% confidence interval [CI] 14.7-23.3), placental abruption (1.0/10,000, adjusted OR 14.6, 95% CI 11.2-19.0), severe preeclampsia (0.8/10,000, adjusted OR 10.4, 95% CI 7.7-14.2), and intrauterine fetal demise (0.7/10,000, adjusted OR 5.5, 95% CI 3.9-7.8). The most common etiologies of massive blood transfusion were abnormal placentation (26.6% of cases), uterine atony (21.2%), placental abruption (16.7%), and postpartum hemorrhage associated with coagulopathy (15.0%). A disproportionate number of women who received a massive blood transfusion experienced severe morbidity including renal failure, acute respiratory distress syndrome, sepsis, and in-hospital death. Conclusion Massive blood transfusion was infrequent, regardless of facility size. In the presence of known risk for receipt of massive blood transfusion, women should be informed of this possibility, should deliver in a well-resourced facility if possible, and should receive appropriate blood product preparation and venous access in advance of delivery. Level of evidence : II.

Objectives Studies indicate high sodium and low potassium intake can increase blood pressure suggesting the ratio of sodium-to-potassium may be informative. Yet, limited studies examine the association of the sodium-to-potassium ratio with blood pressure and hypertension. Methods We analyzed data on 10,563 participants aged ≥20 years in the 2005–2010 National Health and Nutrition Examination Survey who were neither taking anti-hypertensive medication nor on a low sodium diet. We used measurement error models to estimate usual intakes, multivariable linear regression to assess their associations with blood pressure, and logistic regression to assess their associations with hypertension. Results The average usual intakes of sodium, potassium and sodium-to-potassium ratio were 3,569 mg/d, 2,745 mg/d, and 1.41, respectively. All three measures were significantly associated with systolic blood pressure, with an increase of 1.04 mmHg (95% CI, 0.27–1.82) and a decrease of 1.24 mmHg (95% CI, 0.31–2.70) per 1,000 mg/d increase in sodium or potassium intake, respectively, and an increase of 1.05 mmHg (95% CI, 0.12–1.98) per 0.5 unit increase in sodium-to-potassium ratio. The adjusted odds ratios for hypertension were 1.40 (95% CI, 1.07–1.83), 0.72 (95% CI, 0.53–0.97) and 1.30 (95% CI, 1.05–1.61), respectively, comparing the highest and lowest quartiles of usual intake of sodium, potassium or sodium-to-potassium ratio. Conclusions Our results provide population-based evidence that concurrent higher sodium and lower potassium consumption are associated with hypertension.

From 1976–1980 through 2007–2010, for U.S. adults aged 40–74, a decrease was observed in the prevalence of high LDL–C, as well as an increase in adults using lipid-lowering medications and consuming a diet low in saturated fat. A substantial decline in the prevalence of high LDL–C from 59% to 28% was seen over this same time period. There also were significant increases in the percentage of adults meeting federal dietary guidelines (6) for low dietary saturated-fat intake, from 25% to 42%, between 1976–1980 and 2007–2010; however, no significant changes were observed from 1988–1994 to 2007–2010. Although declines in the proportion of calories from saturated fat have occurred since the 1970s, the average dietary energy intake has increased (7). Use of cholesterol-lowering medication continued to grow steadily, from 5% to 23%, from 1988–1994 to 2007–2010. Despite recent advances in medical treatment, high cholesterol remains a significant public health problem in the United States, with more than one-quarter of adults aged 40–74 having high LDL–C. These findings may provide useful information for evaluation of programs and policy initiatives aimed at reducing the prevalence of high cholesterol in the adult population.

To define the prevalence, indications, and temporal trends in obstetric-related ICU admissions.Descriptive analysis of utilization patterns.All hospitals within the state of Maryland.All antepartum, delivery, and postpartum patients who were hospitalized between 1999 and 2008.None.We identified 2,927 ICU admissions from 765,598 admissions for antepartum, delivery, or postpartum conditions using appropriate International Classification of Diseases, 9th Revision, Clinical Modification codes. The overall rate of ICU utilization was 419.1 per 100,000 deliveries, with rates of 162.5, 202.6, and 54.0 per 100,000 deliveries for the antepartum, delivery, and postpartum periods, respectively. The leading diagnoses associated with ICU admission were pregnancy-related hypertensive disease (present in 29.9% of admissions), hemorrhage (18.8%), cardiomyopathy or other cardiac disease (18.3%), genitourinary infection (11.5%), complications from ectopic pregnancies and abortions (10.3%), nongenitourinary infection (10.1%), sepsis (7.1%), cerebrovascular disease (5.8%), and pulmonary embolism (3.7%). We assessed for changes in the most common diagnoses in the ICU population over time and found rising rates of sepsis (10.1 per 100,000 deliveries to 16.6 per 100,000 deliveries, p = 0.003) and trauma (9.2 per 100,000 deliveries to 13.6 per 100,000 deliveries, p = 0.026) with decreasing rates of anesthetic complications (11.3 per 100,000 to 4.7 per 100,000, p = 0.006). The overall frequency of obstetric-related ICU admission and the rates for other indications remained relatively stable.Between 1999 and 2008, 419.1 per 100,000 deliveries in Maryland were complicated by ICU admission. Hospitals providing obstetric services should plan for appropriate critical care management and/or transfer of women with severe morbidities during pregnancy.

Purpose: To assess the incidence of adverse outcomes in pre-selected laboring patients who received low dose intrathecal morphine as part of the regional technique for labor analgesia. Methods: Retrospective observational study of 205 laboring patients who delivered at a large community hospital between January 2007 and December 2010. All patients received Duramorph, 250 μg, and fentanyl, 25 μg intrathecally. The primary adverse outcome was delayed maternal respiratory depression. Secondary adverse outcomes included high pain scores, low Apgar scores, and postpartum hemorrhage. Results: No cases of respiratory depression requiring naloxone administration were reported during the study. No infants had Apgar scores 4. Conclusion: This study demonstrates that regional analgesia utilizing low doses of intrathecal morphine and fentanyl in selected laboring patients is safe and effective.