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Objective This study aimed to evaluate trends, risk factors, and outcomes associated with infections and sepsis during delivery hospitalizations in the United States. Study Design The 2000–2020 National Inpatient Sample was used for this repeated cross-sectional analysis. Delivery hospitalizations of patients aged 15 to 54 with and without infection and sepsis were identified. Common infection diagnoses during delivery hospitalizations analyzed included (i) pyelonephritis, (ii) pneumonia/influenza, (iii) endometritis, (iv) cholecystitis, (v) chorioamnionitis, and (vi) wound infection. Temporal trends in sepsis and infection during delivery hospitalizations were analyzed. The associations between sepsis and infection and common chronic health conditions including asthma, chronic hypertension, pregestational diabetes, and obesity were analyzed. The associations between clinical, demographic, and hospital characteristics, and infection and sepsis were determined with unadjusted and adjusted logistic regression models with unadjusted odds ratio (OR) and adjusted odds ratios with 95% confidence intervals as measures of association. Results An estimated 80,158,622 delivery hospitalizations were identified and included in the analysis, of which 2,766,947 (3.5%) had an infection diagnosis and 32,614 had a sepsis diagnosis (4.1 per 10,000). The most common infection diagnosis was chorioamnionitis (2.7% of deliveries) followed by endometritis (0.4%), and wound infections (0.3%). Infection and sepsis were more common in the setting of chronic health conditions. Evaluating trends in individual infection diagnoses, endometritis and wound infection decreased over the study period both for patients with and without chronic conditions, while risk for pyelonephritis and pneumonia/influenza increased. Sepsis increased over the study period for deliveries with and without chronic condition diagnoses. Risks for adverse outcomes including mortality, severe maternal morbidity, the critical care composite, and acute renal failure were all significantly increased in the presence of sepsis and infection. Conclusion Endometritis and wound infections decreased over the study period while risk for sepsis increased. Infection and sepsis were associated with chronic health conditions and accounted for a significant proportion of adverse obstetric outcomes including severe maternal morbidity. Key Points Sepsis increased over the study period for deliveries with and without chronic condition diagnoses. Endometritis and wound infection decreased over the study period. Infection and sepsis accounted for a significant proportion of adverse obstetric outcomes. [ABSTRACT FROM AUTHOR]

Author(s): Jean-Ju Sheen [sup.1] [sup.2] , Heather A. Smith [sup.1] [sup.3] , Brian Tu [sup.1] , Ying Liu [sup.1] [sup.4] , Desmond Sutton [sup.1] [sup.2] , Peter S. Bernstein [sup.1] [...], Objectives To identify risk factors associated with urban postpartum emergency department utilization. Methods This case-control study included 100 matched pairs of postpartum women who had delivered at a large, integrated urban medical system in Bronx, New York, in 2012-2013, with the cases having had an emergency department visit within 42 days of delivery. The cases, identified utilizing administrative and billing data, were matched 1:1 with controls by labor unit, delivery mode and date, excluding nonviable pregnancies. The controls did not have a known postpartum emergency department visit. Variables were abstracted from administrative data and chart review, and included demographics, antenatal/intrapartum/postpartum complications and neonatal intensive care unit admission. Factors associated with puerperal emergency department use were identified via univariate and multivariable analyses. Results Following conditional logistic regression, primiparity [54% vs. 32%, aOR 5.91, 95% CI 2.34-14.91], public insurance [70% vs. 56%, aOR 4.22, 95% CI 1.60-11.12], weekend delivery [30% vs. 26%, aOR 7.61, 95% CI 1.15-52.43] and delivery-related complications [47% vs. 28%, aOR 2.95, 95% CI 1.16-7.51] were associated with an increased risk of postpartum emergency department use, while women of younger ages (17-24 years old) were less likely to have postpartum emergency department use [aOR 0.23, 95% CI 0.07-0.74]. Univariate analysis of individual events within the composite variables showed an association between gestational hypertension/pre-eclampsia and postpartum emergency department use [28% vs. 13% OR 2.60, 95% CI 1.26-5.39]. Psychiatric history, social instability, preterm delivery/neonatal intensive care unit admission, pre-existing medical/antepartum conditions and prolonged postpartum stay were not associated. Conclusions for Practice Delivery-related complications, delivery timing, and certain sociodemographic factors are identifiable risk factors for increased postpartum emergency department utilization. These may be targeted for development of interventions improving puerperal care and potentially preventing emergency department visits, which are costly to the health system and disruptive to the lives of women and their families.

Measurement of obstetric hemorrhage-related morbidity is important for quality assurance purposes but presents logistical challenges in large populations. Billing codes are typically used to track severe maternal morbidity but may be of suboptimal validity. The objective of this study was to evaluate the validity of billing code diagnoses for hemorrhage-related morbidity compared to data obtained from the electronic medical record. Deliveries occurring between July 2014 and July 2017 from three hospitals within a single system were analyzed. Three outcomes related to obstetric hemorrhage that are part of the Centers for Disease Control and Prevention definition of severe maternal morbidity (SMM) were evaluated: (i) transfusion, (ii) disseminated intravascular coagulation (DIC), and (iii) acute renal failure (ARF). ICD-9-CM and ICD-10-CM for these conditions were ascertained and compared to blood bank records and laboratory values. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) with 95% confidence intervals (CI) were calculated. Ancillary analyses were performed comparing codes and outcomes between hospitals and comparing ICD-9-CM to ICD-10-CM codes. Comparisons of categorical variables were performed with the chi-squared test. T-tests were used to compare continuous outcomes. 35,518 deliveries were analyzed. 786 women underwent transfusion, 168 had serum creatinine ≥1.2 mg/dL, and 99, 40, and 16 had fibrinogen ≤200, ≤150, and ≤100 mg/dL, respectively. Transfusion codes were 65% sensitive (95% CI 62–69%) with a 91% PPV (89–94%) for blood bank records of transfusion. DIC codes were 22% sensitive (95% CI 15–32%) for a fibrinogen cutoff of ≤200 mg/dL with 15% PPV (95% CI 10–22%). Sensitivity for ARF was 33% (95% CI 26–41%) for a creatinine of 1.2 mg/dL with a PPV of 63% (95% CI 52–73%). Sensitivity of ICD-9-CM for transfusion was significantly higher than ICD-10-CM (81%, 95% CI 76–86% versus 56%, 95% CI 51–60%, p <.01). Evaluating sensitivity of codes by individual hospitals, sensitivity of diagnosis codes for transfusion varied significantly (Hospital A 47%, 95% CI 36–58% versus Hospital B 63%, 95% CI 58–67% versus Hospital C 80%, 95% CI 74–86%, p <.01). Use of administrative billing codes for postpartum hemorrhage complications may be appropriate for measuring trends related to disease burden and resource utilization, particularly in the case of transfusion, but may be suboptimal for measuring clinical outcomes within and between hospitals. [ABSTRACT FROM AUTHOR]

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

Objective  This study aimed to analyze whether hospital safety-net burden status is associated with increased risk for severe maternal morbidity (SMM) and postpartum readmissions. Study Design  The 2010 to 2014 Nationwide Readmissions Database was utilized for this retrospective cohort study. Hospitals were categorized as high-burden hospitals (25% of hospitals with the highest safety-net burden), medium-burden hospitals (50% of hospitals with intermediate safety-net burden), and low-burden hospitals (25% of hospitals with the lowest safety-net burden) based on the proportions of Medicaid or uninsured patients. Risk for (1) SMM, (2) 60-day postpartum readmissions, and (3) SMM during postpartum readmissions was analyzed. Unadjusted and adjusted log-linear regression models were performed, respectively, for these outcomes with unadjusted risk ratio (RR) and adjusted RR (aRR) as measures of effect. Adjusted models included demographic, hospital, and clinical factors. Results  High-burden safety-net status was associated with increased risk for SMM compared with low-burden safety-net status in both unadjusted (RR: 1.51, 95% confidence interval [CI]: 1.50–1.53) and adjusted analyses (aRR: 1.27, 95% CI: 1.25–1.30). High-burden status was also associated with increased risk for readmissions in unadjusted analyses (RR: 1.42, 95% CI: 1.40–1.44), although this risk was attenuated in adjusted analyses (aRR: 1.07, 95% CI: 1.06–1.08). High-burden status was associated with significantly increased risk for readmission for uterine infections, hypertensive diseases of pregnancy, and psychiatric diagnoses. High-burden status was not associated with severe morbidity during readmissions in adjusted or unadjusted analyses (RR: 1.02, 95% CI: 0.98–1.05; aRR: 0.95, 95% CI: 0.92–0.99). Conclusion  This study found that high safety-net burden hospitals may be a higher risk setting for obstetric care. Improvement of outcomes in high-burden settings may be important in overall efforts to reduce maternal risk. [ABSTRACT FROM AUTHOR]

Objective  This study was aimed to review 4 weeks of universal novel coronavirus disease 2019 (COVID-19) screening among delivery hospitalizations, at two hospitals in March and April 2020 in New York City, to compare outcomes between patients based on COVID-19 status and to determine whether demographic risk factors and symptoms predicted screening positive for COVID-19. Study Design  This retrospective cohort study evaluated all patients admitted for delivery from March 22 to April 18, 2020, at two New York City hospitals. Obstetrical and neonatal outcomes were collected. The relationship between COVID-19 and demographic, clinical, and maternal and neonatal outcome data was evaluated. Demographic data included the number of COVID-19 cases ascertained by ZIP code of residence. Adjusted logistic regression models were performed to determine predictability of demographic risk factors for COVID-19. Results  Of 454 women delivered, 79 (17%) had COVID-19. Of those, 27.9% (n  = 22) had symptoms such as cough (13.9%), fever (10.1%), chest pain (5.1%), and myalgia (5.1%). While women with COVID-19 were more likely to live in the ZIP codes quartile with the most cases (47 vs. 41%) and less likely to live in the ZIP code quartile with the fewest cases (6 vs. 14%), these comparisons were not statistically significant (p  = 0.18). Women with COVID-19 were less likely to have a vaginal delivery (55.2 vs. 51.9%, p  = 0.04) and had a significantly longer postpartum length of stay with cesarean (2.00 vs. 2.67days, p  < 0.01). COVID-19 was associated with higher risk for diagnoses of chorioamnionitis and pneumonia and fevers without a focal diagnosis. In adjusted analyses, including demographic factors, logistic regression demonstrated a c-statistic of 0.71 (95% confidence interval [CI]: 0.69, 0.80). Conclusion  COVID-19 symptoms were present in a minority of COVID-19-positive women admitted for delivery. Significant differences in obstetrical outcomes were found. While demographic risk factors demonstrated acceptable discrimination, risk prediction does not capture a significant portion of COVID-19-positive patients. Key Points COVID-19 symptoms were present in a minority of COVID-19-positive women admitted. COVID-19 symptomatology did not appear to differ before or after the apex of infection in New York. Demographic risk factors are unlikely to capture a significant portion of COVID-19-positive patients. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate risk for postpartum readmissions and associated severe morbidity by maternal age.Materials and Methods: This retrospective cohort study used the Nationwide Readmissions Database to analyze 60-day all-cause postpartum readmission risk from 2010 to 2014. Risk for severe maternal morbidity (SMM) during readmission was ascertained using criteria from the Centers for Disease Control and Prevention. The primary exposure of interest was maternal age. Outcomes included time to readmission, risk of readmission, and risk for SMM during readmission. Multivariable log linear analyses adjusting for patient, obstetric, and hospital factors were conducted to assess readmission and SMM risk with adjusted risk ratios (aRRs) with 95% confidence intervals (CIs) as measures of effect.Results: Between 2010 and 2014, we identified 15.7 million deliveries, 15% of which were to women aged 35 or older. The 60-day all-cause readmission rate was 1.7%. Of these, 13% were complicated by SMM. Age-stratification revealed that women 35 and older were at increased risk for readmission and increased risk for SMM. The majority of readmissions occurred within the first 20 days regardless of age; although, women 35 and older were more likely to be admitted within the first 10 days of discharge. Patients ages 35-39, 40-44, and >44 years had 9% (95% CI 7-10%), 37% (95% CI 34-39%), and 66% (95% CI 55-79%) significantly higher rates of postpartum readmission when compared to women age 25-29. Women 35-39, 40-44, and >44 years of age had a 15% (95% CI 10-21%), 26% (95% CI 18-34%), and 56% (95% CI 25-94%) higher risk of a readmission with SMM than women 25-29.Conclusions: AMA women are at higher risk for both postpartum readmission and severe morbidity during readmission. Women older than 35 years represent the group most likely to experience complications requiring readmission, with the highest risk age 40 and older. [ABSTRACT FROM AUTHOR]

Objective  To review obstetric personnel absences at a hospital during the initial peak of coronavirus disease 2019 (COVID-19) infection risk in New York City from March 25 to April 21, 2020. Study Design  This retrospective study evaluated absences at Morgan Stanley Children's Hospital. Clinical absences for (1) Columbia University ultrasonographers, (2) inpatient nurses, (3) labor and delivery operating room (OR) technicians, (4) inpatient obstetric nurse assistants, and (5) attending physicians providing inpatient obstetric services were analyzed. Causes of absences were analyzed and classified as illness, vacation and holidays, leave, and other causes. Categorical variables were compared with the chi-square test or Fisher's exact test. Results  For nurses, absences accounted for 1,052 nursing workdays in 2020 (17.2% of all workdays) compared with 670 (11.1%) workdays in 2019 (p  < 0.01). Significant differentials in days absent in 2020 compared with 2019 were present for (1) postpartum nurses (21.9% compared with 12.9%, p  < 0.01), (2) labor and delivery nurses (14.8% compared with 10.6%, p  < 0.01), and (3) antepartum nurses (10.2% compared with 7.4%, p  = 0.03). Evaluating nursing assistants, 24.3% of workdays were missed in 2020 compared with 17.4% in 2019 (p  < 0.01). For ultrasonographers, there were 146 absences (25.2% of workdays) in 2020 compared with 96 absences (16.0% of workdays) in 2019 (p  < 0.01). The proportion of workdays missed by OR technicians was 22.6% in 2020 and 18.3% in 2019 (p  = 0.25). Evaluating attending physician absences, a total of 78 workdays were missed due to documented COVID-19 infection. Evaluating the causes of absences, illness increased significantly between 2019 and 2020 for nursing assistants (42.6 vs. 57.4%, p  = 0.02), OR technicians (17.1 vs. 55.9%, p  < 0.01), and nurses (15.5 vs. 33.7%, p  < 0.01). Conclusion  COVID-19 outbreak surge planning represents a major operational issue for medical specialties such as critical care due to increased clinical volume. Findings from this analysis suggest it is prudent to devise backup staffing plans. Key Points 1) COVID-19 outbreak surge planning represents a major operational issue for obstetrics. 2) Inpatient obstetric volume cannot be reduced. 3) Staffing contingencies plans for nurses, sonographers, and physicians may be required. [ABSTRACT FROM AUTHOR]

As New York City became an international epicenter of the novel coronavirus disease 2019 (COVID-19) pandemic, telehealth was rapidly integrated into prenatal care at Columbia University Irving Medical Center, an academic hospital system in Manhattan. Goals of implementation were to consolidate in-person prenatal screening, surveillance, and examinations into fewer in-person visits while maintaining patient access to ongoing antenatal care and subspecialty consultations via telehealth virtual visits. The rationale for this change was to minimize patient travel and thus risk for COVID-19 exposure. Because a large portion of obstetric patients had underlying medical or fetal conditions placing them at increased risk for adverse outcomes, prenatal care telehealth regimens were tailored for increased surveillance and/or counseling. Based on the incorporation of telehealth into prenatal care for high-risk patients, specific recommendations are made for the following conditions, clinical scenarios, and services: (1) hypertensive disorders of pregnancy including preeclampsia, gestational hypertension, and chronic hypertension; (2) pregestational and gestational diabetes mellitus; (3) maternal cardiovascular disease; (4) maternal neurologic conditions; (5) history of preterm birth and poor obstetrical history including prior stillbirth; (6) fetal conditions such as intrauterine growth restriction, congenital anomalies, and multiple gestations including monochorionic placentation; (7) genetic counseling; (8) mental health services; (9) obstetric anesthesia consultations; and (10) postpartum care. While telehealth virtual visits do not fully replace in-person encounters during prenatal care, they do offer a means of reducing potential patient and provider exposure to COVID-19 while providing consolidated in-person testing and services. Key Points Telehealth for prenatal care is feasible. Telehealth may reduce coronavirus exposure during prenatal care. Telehealth should be tailored for high risk prenatal patients. [ABSTRACT FROM AUTHOR]

Objective  To characterize risk and temporal trends for preeclampsia and related outcomes by maternal age. Study Design  Deliveries to women aged 15 to 54 years in the 1998 to 2014 National Inpatient Sample who had a diagnosis of preeclampsia, eclampsia, or both were included in the analysis. Age was categorized as 15 to 17, 18 to 24, 25 to 29, 30 to 34, 35 to 39, 40 to 44, and 45 to 54 years. The primary outcome was temporal trends in preeclampsia based on maternal age. Secondary outcomes analyzed included risk for severe maternal morbidity. Results  The proportion of women with preeclampsia aged 15 to 24 years decreased from 42.3% in 1998 to 30.1% in 2014, while preeclampsia among those 30 to 54 years increased from 32.9 to 43.7%. Preeclampsia risk increased for all groups over the study period. Risk for severe morbidity by age group with and without transfusion was "U-shaped," with risk highest for women 18 to 24 and 40 to 54 years. The risk for abruption, acute renal failure, acute heart failure or pulmonary edema, and stroke was lowest for women aged 15 to 24 years and increased in a "dose-dependent" manner with increasing maternal age. In contrast, eclampsia risk was highest for women aged 15 to 17 years. Conclusion  With a changing demographic profile of preeclampsia, older women accounted for an increasing proportion of preeclampsia and related adverse outcomes. [ABSTRACT FROM AUTHOR]