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Background: Most patients with signs or symptoms (s/s) of suspected preeclampsia are not diagnosed with preeclampsia. We sought to determine and compare the prevalence of s/s, pregnancy outcomes, and costs between patients with and without diagnosed preeclampsia., Methods: This retrospective cohort study analyzed a large insurance research database. Pregnancies with s/s of preeclampsia versus a confirmed preeclampsia diagnosis were identified using International Classification of Diseases codes. S/s include hypertension, proteinuria, headache, visual symptoms, edema, abdominal pain, and nausea/vomiting. Pregnancies were classed as 1) s/s of preeclampsia without a confirmed preeclampsia diagnosis (suspicion only), 2) s/s with a confirmed diagnosis (preeclampsia with suspicion), 3) diagnosed preeclampsia without s/s recorded (preeclampsia only), and 4) no s/s, nor preeclampsia diagnosis (control)., Results: Of 1,324,424 pregnancies, 29.2 % had ≥1 documented s/s of suspected preeclampsia, and 14.2 % received a preeclampsia diagnosis. Hypertension and headache were the most common s/s, leading 20.2 % and 9.2 % pregnancies developed to preeclampsia diagnosis, respectively. Preeclampsia, with or without suspicion, had the highest rates of hypertension-related severe maternal morbidity (HR [95 % CI]: 3.0 [2.7, 3.2] and 3.6 [3.3, 4.0], respectively) versus controls. A similar trend was seen in neonatal outcomes such as preterm delivery and low birth weight. Cases in which preeclampsia was suspected but not confirmed had the highest average total maternal care costs ($6096 [95 % CI: 602, 6170] over control)., Conclusion: There is a high prevalence but poor selectivity of traditional s/s of preeclampsia, highlighting a clinical need for improved screening method and cost-effectiveness disease management., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: YJ and MG are employees of Roche Diagnostics and hold stocks. LK, JH and YX were employees of Roche Diagnostics at the time the study was conducted. S-XN has received support for travel and meeting attendance, and consulting fees, both from Roche Diagnostics. JJS has received payments from Roche Diagnostics as a consultant for the current project and as an advisory board member. SR reports serving as a consultant to Roche Diagnostics and ThermoFisher Scientific, and has received funding from Roche Diagnostics and Siemens for studies related to the use of angiogenic factors in pregnancy. AM has received statistical consulting fees from Roche Diagnostics. KK, MK and JE report no conflicts of interest. WFP reports research grants from Brainbox, and Quidel; serving as a consultant for Abbott, Brainbox, Instrument Labs, Janssen, Osler, Roche, Siemens, Spinchip, and Vifor; as well as having stock/ownership interests in AseptiScope Inc, Brainbox Inc, Braincheck Inc, Coagulo Inc, Comprehensive Research Associates LLC, Comprehensive Research Management Inc, Emergencies in Medicine LLC, Fast Inc, Forrest Devices, Ischemia DX LLC, Lucia Inc, Prevencio Inc, RCE Technologies, ROMTech, ScPharma, Trivirum Inc, and Upstream Inc. DW has received honoraria for scientific presentations from Roche Diagnostics, Inc., and Progenity, Inc., and consulting fees for advisory board attendance from Progenity, Inc., and Quidel, Inc., (Copyright © 2024 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Objective: Preeclampsia is a major obstetric disorder that can lead to severe maternal, fetal and infant outcomes. In women with suspected preeclampsia, measurement of the soluble fms-like tyrosine kinase-1 (sFlt1) and placental growth factor (PlGF) ratio has been shown to have a high negative predictive value (>97%). Our aim was to estimate the value to the US healthcare system of adopting this test into clinical practice., Study Design: An economic model was developed for the evaluation of suspected preeclampsia from a US payer perspective using data from a US observational study of 459 women evaluated between 23 and 34.6 weeks. Test results were not available to clinicians. The model compares two strategies for managing suspected preeclampsia: standard care versus a biomarker-informed pathway utilizing the sFlt1/PlGF ratio., Results: Utilization of the sFlt1/PlGF ratio test reduced the number of women admitted for suspected preeclampsia by 34-49%. Despite fewer admissions, a higher proportion of women admitted to hospital subsequently developed preeclampsia, and the proportion of women not admitted who would subsequently develop preeclampsia remained low (3.2%-6.7%). Cost savings arising from a reduction in admissions are estimated to be $1050 in the base case; varying the hospitalization cost ±25% would lead to savings in the range $771 to $1330 per patient at 2020 prices., Conclusion: Adopting the sFlt1/PlGF ratio test as an adjunct to clinical criteria improves the assessment of risk in women presenting with suspicion of preeclampsia and has the potential to safely reduce unnecessary admissions and save costs., (Copyright © 2021 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Objective: American College of Cardiology and American Heart Association (ACC/AHA) published new guidelines which lower the cut-off for hypertension. We sought to evaluate the impact of these guidelines to cost and benefit of various low-dose aspirin prophylaxis approaches., Study Design: Decision tree analysis was created using R software to evaluate four approaches to aspirin prophylaxis in the United States: no aspirin, United States Preventive Service Task Force (USPSTF) with Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) hypertension guidelines, USPSTF with ACC/AHA hypertension guidelines, as well as universal aspirin prophylaxis. This model was executed to simulate a hypothetical cohort of 4 million pregnant women in the United States., Results: The new guidelines would expand the aspirin eligibility by 8% (76,953 women) in the USPSTF guidelines. Even with this increased eligibility, the USPSTF guidelines continue to be the approach with the most cost savings ($386.5 million) when compared with universal aspirin and no aspirin prophylaxis. The new hypertension guidelines are projected to increase the cost savings of the USPSTF approach by $9.4 million., Conclusion: Despite the small change in aspirin prophylaxis, using ACC/AHA definition of hypertension still results in an annual cost-saving of $9.4 million in the United States when compared with JNC7., Competing Interests: None declared., (Thieme. All rights reserved.)

The temporal trend of hospitalizations, cost, and outcomes associated with preeclampsia with severe features have been inadequately studied. The publicly available Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) database was accessed to examine the temporal trend of total number of discharges, age, death, and mean charges per admission associated with preeclampsia with severe features. Eleven-year temporal trends (2004 to 2014) of these measures were compared using linear regression and run charts using the statistical process control rule. From 2004 to 2014, the total number of discharges related to preeclampsia with severe features increased both for Hawai'i and the U.S. (United States) (Hawai'i: 104 to 231; U.S.: 35,082 to 55,235; both P <.0001). The corresponding rates of discharges per 100,000 population also both increased (Hawai'i: 8.2 to 16.3; U.S.: 12.0 to 17.3; both P <.0001). Comparing the temporal trends between Hawai'i and the U.S., Hawai'i had a significantly higher average annual increase in the rate of incidence than the national level (an annual increase rate of 9.2% in Hawai'i vs 4.2% nationally; P =.0004). The cost of hospitalization for preeclampsia with severe features also showed an increased trend for both Hawai'i and the U.S. (Hawai'i: 33.1% increase, P =.0005; U.S.: 41.1% increase, P <.0001). In the U.S., in-hospital mortality rates associated with this condition decreased from 0.09% in 2004 to 0.02% in 2014 ( P =.03). In conclusion, the number of discharges related to preeclampsia with severe features increased over an 11-year period in Hawai'i and the U.S., and the rate of increase was higher in Hawai'i than the U.S. Maternal mortality rates from this condition also declined over the study period., Competing Interests: None of the authors identify any conflicts of interest.

Background: Peripartum cardiomyopathy (PPCM) and preeclampsia are strongly associated, yet a description of risk factors for PPCM among women with preeclampsia is currently lacking. Additionally, the effect of preeclampsia on PPCM-related outcomes is not well known., Methods: We constructed a cohort of delivery admissions from 2011 to 2014 using a large US administrative database (Marketscan). We assessed risk factors for the development of PPCM among women with preeclampsia. We compared the risks of major adverse cardiovascular events (MACE) at 6 months between PPCM with co-incident preeclampsia (pePPCM) and PPCM without preeclampsia (npePPCM)., Results: We included 1,024,035 pregnancies, of which 64,503 (6.3%) had preeclampsia. A total of 874 had PPCM (283 with preeclampsia and 591 without preeclampsia). Among women with preeclampsia, clinical risk factors for PPCM consisted in chronic kidney disease (OR 3.18, 95% CI [1.51, 6.69]), multiple pregnancy (OR 2.11, 95% CI [1.49, 2.98]), chronic hypertension (OR 1.88, 95% CI [1.43, 2.47]), advanced maternal age (OR 1.82, 95% CI [1.42, 2.33]), and type 2 diabetes (OR 1.58, 95% CI [1.00, 2.48]). Women with pePPCM had a higher risk of MACE than women with npePPCM (adjusted RR 1.29, 95% CI [1.06, 1.57]) due to increased rates of clinical heart failure and pulmonary embolism in the pePPCM group. Mortality did not differ between groups., Conclusion: Preeclamptic women with risk factors for PPCM and women with pePPCM at increased risk of MACE should be followed closely. Further studies are required to determine whether preeclampsia affects the long-term prognosis of women with PPCM., (Copyright © 2019 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Objectives: Hypertensive disorders of pregnancy (HDP) represent the most common cause of maternal-fetal morbidity and mortality. Yet, the prevalence and cost of postpartum (42-day) readmission (PPR) among HDP-complicated pregnancies in the United States remains unknown. This study provides national prevalence and cost estimates of HDP, and examine factors associated with potentially preventable PPR following HDP-complicated pregnancies., Method: The 2013 and 2014 Nationwide Readmissions Databases were used to investigate HDP and PPR among delivery hospitalizations to women aged 15-49 years. PPR rates, length of stay, and costs were stratified by four HDP subtypes based on timing and severity of their condition. Survey logistic regression was employed to generate adjusted odds ratios for the association between HDP and PPR., Result: In 2013 and 2014, there were 6.3 million delivery hospitalizations; 666 506 (10.6%) were complicated by HDP. Annually, HDP was responsible for higher rates of potentially preventable PPR. Among HDP-complicated pregnancies, the 42-day all-cause PPR rate ranged from 2.5% (gestational hypertension) to 4.6% (superimposed preeclampsia/eclampsia). Compared with normotensive pregnancies, HDP resulted in an excess 404 800 hospital days and inpatient care costs of $731 million. Even after controlling for patient-level and hospital-level confounders, all hypertensive subgroups continued to have at least two-fold, statistically significant, increased odds of potentially preventable PPR., Conclusion: HDP is associated with increased risk of PPR and substantial medical costs. Preventive efforts should be made to identify women at increased risk of PPR during hospitalization so that transition care intervention can be initiated.

Objective: To develop a decision model to evaluate the risks, benefits, and costs of different approaches to aspirin prophylaxis for the approximately 4 million pregnant women in the United States annually., Methods: We created a decision model to evaluate four approaches to aspirin prophylaxis in the United States: no prophylaxis, prophylaxis per American College of Obstetricians and Gynecologists (the College) recommendations, prophylaxis per U.S. Preventive Services Task Force recommendations, and universal prophylaxis. We included the costs associated with aspirin, preeclampsia, preterm birth, and potential aspirin-associated adverse effects. TreeAge Pro 2011 was used to perform the analysis., Results: The estimated rate of preeclampsia would be 4.18% without prophylaxis compared with 4.17% with the College approach in which 0.35% (n=14,000) of women receive aspirin, 3.83% with the U.S. Preventive Services Task Force approach in which 23.5% (n=940,800) receive aspirin, and 3.81% with universal prophylaxis. Compared with no prophylaxis, the U.S. Preventive Services Task Force approach would save $377.4 million in direct medical care costs annually, and universal prophylaxis would save $365 million assuming 4 million births each year. The U.S. Preventive Services Task Force approach is the most cost-beneficial in 79% of probabilistic simulations. Assuming a willingness to pay of $100,000 per neonatal quality-adjusted life-year gained, the universal approach is the most cost-effective in more than 99% of simulations., Conclusion: Both the U.S. Preventive Services Task Force approach and universal prophylaxis would reduce morbidity, save lives, and lower health care costs in the United States to a much greater degree than the approach currently recommended by the College.

Context: Despite known adverse health effects, many women continue to smoke during pregnancy. Public attention has now focused on the economic as well as health effects of this behavior., Objective: To estimate health care costs associated with smoking-attributable cases of placenta previa, abruptio placenta, ectopic pregnancy, preterm premature rupture of the membrane (PPROM), pre-eclampsia, and spontaneous abortion., Design: Pooled odds ratios were used with data on total cases to estimate smoking-attributable cases. Estimated average costs for cases of ectopic pregnancy and spontaneous abortion were used to estimate smoking-attributable health care costs for these conditions. Incremental costs, or costs above those for a "normal" delivery, were used to estimate smoking-attributable costs of placenta previa, abruptio placenta, PPROM, and pre-eclampsia associated with delivery., Setting: National estimates for 1993., Participants: Data from the National Hospital Discharge Survey (NHDS) and claims data from a sample of large, self-insured employers across the country., Results: Smoking-attributable costs ranged from $1.3 million for PPROM to $86 million for ectopic pregnancy. Smoking during pregnancy apparently protects against pre-eclampsia and saves between $36 and $49 million, depending on smoking prevalence. Over all conditions smoking-attributable costs ranged from $135 to $167 million., Conclusions: Smoking during pregnancy is a preventable cause of higher health care costs for the conditions studied. While smoking during pregnancy was found to be protective against pre-eclampsia and, hence, saves costs, the net costs were still positive and significant. Effective smoking-cessation programs can reduce health care costs but clinicians will perhaps need to manage increased cases of pre-eclampsia in a cost-effective manner.