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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]

Objective: To evaluate the prevalence, timing, clinical risk factors, and adverse outcomes associated with postpartum readmissions for maternal sepsis., Methods: We conducted a retrospective cohort study of delivery hospitalizations and 60-day postpartum readmissions for females aged 15-54 years with and without sepsis using the 2016-2020 Nationwide Readmissions Database. Temporal trends in sepsis diagnoses during delivery hospitalizations and 60-day postpartum readmissions were analyzed with the National Cancer Institute's Joinpoint Regression Program to estimate the average annual percent change with 95% CIs. Logistic regression models were fit to determine whether delivery hospitalization characteristics were associated with postpartum sepsis readmissions, and unadjusted and adjusted odds ratios with 95% CIs were reported. Adverse outcomes associated with sepsis during delivery hospitalization and readmission were described, including death, severe morbidity, a critical care composite, and renal failure., Results: Overall, 15,268,190 delivery hospitalizations and 256,216 associated 60-day readmissions were included after population weighting, of which 16,399 (1.1/1,000 delivery hospitalizations) had an associated diagnosis of sepsis at delivery, and 20,130 (1.3/1,000 delivery hospitalizations) had an associated diagnosis of sepsis with postpartum readmission. A sepsis diagnosis was present in 7.9% of all postpartum readmissions. Characteristics associated with postpartum sepsis readmission included younger age at delivery, Medicaid insurance, lowest median ZIP code income quartile, and chronic medical conditions such as obesity, pregestational diabetes, and chronic hypertension. Postpartum sepsis readmissions were associated with infection during the delivery hospitalization, including intra-amniotic infection or endometritis, wound infection, and delivery sepsis. Sepsis diagnoses were associated with 24.4% of maternal deaths at delivery and 38.4% postpartum, 2.2% cases of nontransfusion severe morbidity excluding sepsis at delivery and 13.6% postpartum, 15.6% of critical care composite diagnoses at delivery and 30.1% postpartum, and 11.1% of acute renal failure diagnoses at delivery and 36.4% postpartum., Conclusion: Sepsis accounts for a significant proportion of postpartum readmissions and is a major contributor to adverse outcomes during delivery hospitalizations and postpartum readmissions., Competing Interests: Financial Disclosure Mary E. D'Alton had a senior leadership role in ACOG II's Safe Motherhood Initiative, which received unrestricted funding from Merck for Mothers. Alexander Friedman is supported by funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (1R01HD104943); however, this funding was not used to support this research. He reports serving on a panel for Sage Therapeutics and Biogen. Timothy Wen serves as a consultant on the medical advisory board for Delfina, Inc. Dena Goffman serves on the scientific advisory board for the Jada device through Organon and the Cooper Surgical Obstetrical Safety Council. She reports that her institution received funding from the NICHD EnCore Moms maternal sepsis and the NICHD Obstetric Hemorrhage Technical Skill Simulation. Lisa Nathan reports receiving payment from Organon. Jean Ju Sheen reports receiving payment from UpToDate. Money was paid to their institution from Materna Medical (clinical trial for Prep vaginal dilator device in labor). The other authors did not report any potential conflicts of interest., (Copyright © 2023 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

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.., Competing Interests: M.E.A. had a senior leadership role in ACOG II's Safe Motherhood Initiative which received unrestricted funding from Merck for Mothers. The other authors did not report any potential conflicts of interest., (Thieme. All rights reserved.)

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., Competing Interests: M.E.D. had a senior leadership role in ACOG II's Safe Motherhood Initiative which received unrestricted funding from Merck for Mothers. The other authors did not report any potential conflicts of interest., (Thieme. All rights reserved.)

Maternal morbidity and mortality have gained major attention recently, spurred on by rising domestic rates even as maternal mortality decreases in Europe. A major driver of morbidity and mortality among delivering women is postpartum hemorrhage (PPH). PPH is currently phenotyped using the subjective measure of 'Estimated blood loss' (EBL), which has been shown to be unreliable for tracking quality. Here we present a framework for phenotyping PPH into multiple severity levels, using a combination of data-driven techniques and expert-derived clinical indicators. We validate the framework by predicting large drops in hematocrit and quantitative blood loss, finding that the framework performs better in predicting coded PPH than a hematocrit-based predictor or predictors based on other metrics such as blood transfusions, and does better in predicting quantitative blood loss, a gold standard metric for blood loss that we have for a subset of patients, than any predictor we could build using hematocrit drops alone. In all, we present a principled framework that can be used to phenotype PPH in hospitals using readily available EHR data, and that will perform with more granularity and accuracy than existing methods., (©2019 AMIA - All rights reserved.)

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., Competing Interests: J.D.W. has served as a consultant for Tesaro and Clovis Oncology. M.E.D. had a leadership role with ACOG II's Safe Motherhood Initiative which received funding from Merck for Mothers. The other authors report no conflict of interest., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Maternal race may be an important risk factor for postpartum readmissions and associated adverse outcomes., Objective: To determine the association of race with serious complications during postpartum readmissions., Study Design: This repeated cross-sectional analysis used the National (Nationwide) Inpatient Sample from the Healthcare Cost and Utilization Project from 2012 to 2014. Women ages 15-54 readmitted postpartum after a delivery hospitalization were identified by Centers for Disease Control and Prevention criteria. Race and ethnicity were characterized as non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific islander, Native American, other, and unknown. Overall risk for readmission by race was determined. Risk for severe maternal morbidity during readmissions by race was analyzed. Individual outcomes including pulmonary edema/acute heart failure and stroke also were analyzed by race. Log-linear regression models including demographics, hospital factors, and comorbid risk were used to analyze risk for severe maternal morbidity during postpartum readmissions., Results: Of 11.3 million births, 207,730 (1.8%) women admitted postpartum from 2012 to 2014 were analyzed, including 96,670 white, 47,015 black, and 33,410 Hispanic women. Compared with non-Hispanic white women, non-Hispanic black women were at 80% greater risk of postpartum readmission (95% confidence interval, 79%-82%) whereas Hispanic women were at 11% lower risk of readmission (95% confidence interval, 10%-12%). In unadjusted analysis, compared with non-Hispanic white women, non-Hispanic black women admitted postpartum were at 27% greater risk of severe maternal morbidity (95% confidence interval, 24%-30%) whereas Hispanic women were at 10% lower risk (95% confidence interval, 7%-13%). In the adjusted model, non-Hispanic black women were at 16% greater risk for severe maternal morbidity during readmission than non-Hispanic white women (95% confidence interval, 10%-22%), whereas Hispanic women were at 7% lower risk (95% confidence interval, 1%-12%). Differences in severe maternal morbidity risk between other racial groups and non-Hispanic white women were not significant. In addition to overall morbidity, non-Hispanic black women were at significantly greater risk for eclampsia, acute respiratory distress syndrome, and renal failure than other racial groups (P<.05 all). Black women were at 126% greater risk for pulmonary edema/acute heart failure than white women (95% confidence interval, 117%-136%)., Conclusion: Black women were more likely (1) to be readmitted postpartum, (2) to suffer severe maternal morbidity during readmission, and (3) to suffer life threatening complications such as pulmonary edema/acute heart failure. At-risk women including black women with cardiovascular risk factors may benefit from short-term postpartum follow-up., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to characterize the risk for severe maternal morbidity and other pregnancy complications by maternal age during delivery hospitalizations., Study Design: This retrospective cohort analysis used the Perspective database to characterize the risk for adverse maternal outcomes from 2006 to 2015 based on maternal age. Women were divided into 7 categories based on maternal age: 15-17, 18-24, 25-29, 30-34, 35-39, 40-44, and 45-54 years of age. The primary outcome of this study was severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Secondary outcomes included (1) overall comorbid risk; (2) risk for pregnancy complications such as postpartum hemorrhage, gestational diabetes, preeclampsia, and cesarean delivery; and (3) risk for individual severe morbidity diagnoses such as stroke, embolism, eclampsia, and hysterectomy. Adjusted models were fitted to assess factors associated with severe morbidity with adjusted risk ratios (aRRs) and 95% confidence intervals (CI) as measures of effect. Population weights were applied to create national estimates., Results: Of 36,944,292 deliveries included, 2.5% occurred among women aged 15-17 years (n = 921,236), 29.1% to women aged 18-24 years (n = 10,732,715), 28.6% to women aged 25-29 years (n = 10,564,850), 24.9% to women aged 30-34 years (n = 9,213,227), 12.1% to women aged 35-39 years (n = 4,479,236), 2.6% to women aged 40-44 years (n = 974,289), and 0.2% to women aged 45-54 years (n = 58,739). In unadjusted analyses, severe morbidity was more than 3 times higher (risk ratio [RR], 3.33, 95% confidence interval [CI], 3.03-3.66) for women 45-54 years compared with women 25-29 years. Women aged 40-44, 35-39, and 15-17 years were also at increased risk (RR, 1.83, 95% CI, 1.77-1.89; RR, 1.36, 95% CI, 1.33-1.39; RR, 1.39, 95% CI, 1.34-1.45, respectively). In the adjusted model, the 45-54 year old group was associated with the highest relative risk (aRR, 3.46, 95% CI, 3.15-3.80) followed by the 40-44 year old group (aRR 1.90, 95% CI, 1.84-1.97), the 35-39 year old group (aRR, 1.43, 95% CI, 1.40-1.47), and the 15-17 year old group (aRR, 1.20, 95% CI, 1.15-1.24). Cesarean delivery, preeclampsia, postpartum hemorrhage, and gestational diabetes were most common among women aged 45-54 years, as were thrombosis and hysterectomy., Conclusion: While differential risk was noted across maternal age categories, women aged 45 years old and older were at highest risk for a broad range of adverse outcomes during delivery hospitalizations., (Copyright © 2018. Published by Elsevier Inc.)

Objective: To clarify how race is associated with adverse maternal outcomes and risk for women aged 40 years or older., Methods: This retrospective cohort study used the Nationwide Inpatient Sample for the years 1998-2014. Women aged 40-54 years were included. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, Native American, other, and unknown. Temporal trends in severe maternal morbidity and overall comorbid risk by race in women aged 40 years or older were evaluated as were common pregnancy complications including preeclampsia, gestational diabetes, and cesarean delivery. Adjusted models were created to assess factors associated with severe morbidity., Results: A total of 1,724,694 deliveries were included in this analysis. Severe maternal morbidity increased over the study period from 1.6% in 1998-2000 to 3.0% from 2013 to 2014. Black women had the highest rates of severe morbidity at both the beginning (2.4% in 1998-2000) and the end (4.9% in 2013-2014) of the study period. During this same period, comorbid risk based on medical conditions and other factors increased overall and individually by race. Black women also experienced the absolute largest increase from 1998-2003 to 2010-2014 in risk for acute renal failure, disseminated intravascular coagulation, transfusion, and hysterectomy. Pregnancy complications including preeclampsia, cesarean delivery, and gestational diabetes were more common at the end compared with the beginning of the study for black, white, and Hispanic women. The adjusted risk ratio for overall severe morbidity for black compared with white race was 1.81 (95% CI 1.76-1.87). Black women had a substantially higher risk of death than white women (risk ratio 4.71, 95% CI 3.36-6.61), and Hispanic women had more than twice the risk of death (risk ratio 2.13, 95% CI 1.48-3.07) as white women., Conclusion: Although black women older than 40 years were at increased risk for adverse outcomes and severe morbidity, this differential was of smaller magnitude than reported mortality risk.