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Background Providing continuous health insurance coverage during the perinatal period may increase access to and utilization of labor neuraxial analgesia. This study tested the hypothesis that implementation of the 2010 Dependent Coverage Provision of the Patient Protection and Affordable Care Act, requiring private health insurers to allow young adults to remain on their parent’s plan until age 26, was associated with increased labor neuraxial analgesia use. Methods This study used a natural experiment design and birth certificate data for spontaneous vaginal deliveries in 28 US states between 2009 and 2013. The intervention was the Dependent Coverage Provision, categorized into pre- and post-intervention periods (January 2009-August 2010 and September 2010-December 2013, respectively). The exposure was women age, categorized as exposed (21 to 25 years) and unexposed (27 to 31 years). The outcome was the labor neuraxial analgesia utilization rate. Results Of the 4,515,667 birth certificates analyzed, 3,033,129 (67.2%) indicated labor neuraxial analgesia use. For women aged 21 to 25 years, labor neuraxial analgesia utilization rates were 64.9% during the pre-intervention period and 68.9% during the post-intervention period (difference: 4.0%; 95% CI: 3.9, 4.2). For women aged 27 to 31 years, labor neuraxial analgesia utilization rates were 64.9% during the pre-intervention period and 67.7% during the post-intervention period (difference: 2.8%; 95% CI: 2.7, 2.9). After adjustment, implementation of the Dependent Coverage Provision was associated with a 1.0% (95% CI: 0.8, 1.2) absolute increase in labor neuraxial analgesia utilization rate among women aged 21 to 25 years compared with women aged 27 to 31 years. The increase was statistically significant for White and Hispanic women but not for Black and Other race and ethnicity women. Conclusions Implementation of the Dependent Coverage Provision was associated with a statistically significant increase in labor neuraxial analgesia use, but the small effect size unlikely of clinical significance.

To synthesize the empirical research evidence about the association between Medicaid expansion under the Affordable Care Act (ACA) and increasing perinatal care access and utilization among low-income women.We searched MEDLINE through PubMed (1966-present), EMBASE (Ovid), the Cumulative Index to Nursing and Allied Health (1982-present), PAIS Index (ProQuest), Web of Science (1900-present), and the Cochrane Central Register of Controlled Trials. Our review focuses on the association between Medicaid expansion under the ACA and perinatal care access and utilization, which cannot be subjected to randomized controlled trials, therefore ClinicalTrials.gov was not included in our search.A comprehensive search of the research literature was performed using Covidence. Studies were eligible if they were based on population data and research designs ensuring that the exposure (ie, Medicaid expansion under the ACA) preceded the perinatal care access or utilization outcome, had an appropriate comparison group, presented quantitative data, and examined pregnant or postpartum women. The search in six bibliographic databases returned 1,243 records, with 855 abstracts reviewed, 34 full-text articles screened for eligibility, and nine eligible studies included in the systematic review.Stata 16 software was used to generate summary estimates, forest plots, funnel plots, and heterogeneity statistics. Random effects modeling based on pooled data revealed that Medicaid expansion was associated with a 6.1% increase in Medicaid enrollment for pregnant women (95% CI 1.3-10.9%) and a 3.3% increase in perinatal care utilization (95% CI 0.2-6.3%).Medicaid expansion under the ACA is associated with a modest and statistically significant increase in perinatal care access and utilization among low-income women.

OBJECTIVE To characterize asthma prevalence and outcomes during U.S. delivery hospitalizations. METHODS For this repeated cross-sectional analysis, deliveries to women aged 15-54 years with asthma were identified in the 2000-2018 National Inpatient Sample, which approximates a 20% stratified sample of all hospitalizations nationally. Temporal trends in asthma were analyzed using joinpoint regression to estimate the average annual percent change with 95% CIs. The association of asthma with other comorbid conditions was analyzed. The relationship between asthma and several adverse maternal outcomes was analyzed with unadjusted and adjusted logistic regression models, with unadjusted odds ratios and adjusted odds ratios (aORs) as measures of effect. Risk for and trends in a composite of rare, but severe, respiratory complications also were analyzed. RESULTS An estimated 73,109,790 delivery hospitalizations from 2000 to 2018 were included in the analysis, of which 2,221,644 (3.0%) had a diagnosis of asthma. (Unweighted, the study sample included 15,213,024 deliveries, of which 462,276 [3.0%] had a diagnosis of asthma.) Asthma diagnoses rose from 1.2% in 2000 to 5.3% in 2018, representing an average annual percent change of 8.3% (95% CI 7.4-9.2%). Asthma was more common among women with obesity and chronic hypertension. In adjusted analyses, asthma was associated with severe maternal morbidity (aOR 1.50, 95% CI 1.45-1.55), preeclampsia and gestational hypertension (aOR 1.29, 95% CI 1.26-1.30), postpartum hemorrhage (aOR 1.21, 95% CI 1.19-1.24), cesarean delivery (aOR 1.16, 95% CI 1.15-1.18), gestational diabetes (aOR 1.20, 95% CI 1.18-1.21), venous thromboembolism (aOR 1.79, 95% CI 1.65-1.95), and preterm delivery (aOR 1.27, 95% CI 1.25-1.29). From 2000 to 2018, severe respiratory complications decreased from 72 per 10,000 deliveries with asthma to 14 per 10,000 deliveries with asthma (average annual percent change -9.4%, 95% CI -13.3% to -5.3%). This decreasing risk was offset on a population level by an increase in the risk of asthma. CONCLUSION Asthma is increasing during deliveries, is associated with adverse maternal outcomes, and is associated with comorbid conditions. Severe respiratory complications are decreasing proportionately among deliveries with asthma, but are stable on a population basis.

Objective To analyze racial and ethnic disparities in failure to rescue (ie, death) associated with severe maternal morbidity and describe temporal trends. Methods This was a retrospective cohort study using administrative data. Data for delivery hospitalizations with severe maternal morbidity, as defined by the Centers for Disease Control and Prevention, were abstracted from the 1999-2017 National Inpatient Sample. Race and ethnicity were categorized into non-Hispanic White (reference), non-Hispanic Black, Hispanic, other, and missing. The outcome was failure to rescue from severe maternal morbidity. Disparities were assessed using the failure-to-rescue rate ratio (ratio of the failure-to-rescue rate in the racial and minority group to the failure-to-rescue rate in White women), adjusted for patient and hospital characteristics. Temporal trends in severe maternal morbidity and failure to rescue were assessed. Results During the study period, 73,934,559 delivery hospitalizations were identified, including 993,864 with severe maternal morbidity (13.4/1,000; 95% CI 13.3-13.5). Among women with severe maternal morbidity, 4,328 died (4.3/1,000; 95% CI 4.2-4.5). The adjusted failure-to-rescue rate ratio was 1.79 (95% CI 1.77-1.81) for Black women, 1.39 (95% CI 1.37-1.41) for women of other race and ethnicity, 1.43 (95% CI 1.42-1.45) for women with missing race and ethnicity data, and 1.08 (95% CI 1.06-1.09) for Hispanic women. During the study period, the severe maternal morbidity rate increased significantly in each of the five racial and ethnic groups but started declining in 2012. Meanwhile, the failure-to-rescue rate decreased significantly during the entire study period. Conclusion Despite improvement over time, failure to rescue from severe maternal morbidity remains a major contributing factor to excess maternal mortality in racial and ethnic minority women.

PURPOSE OF REVIEW: Health equity is an important priority for obstetric anesthesia, but describing disparities in perinatal care process and health outcome is insufficient to achieve this goal. Conceptualizing and framing disparity is a prerequisite to pose meaningful research questions. We emphasize the need to hypothesize and test which mechanisms and drivers are instrumental for disparities in perinatal processes and outcomes, in order to target, test and refine effective countermeasures. RECENT FINDINGS: With an emphasis on methodology and measurement, we sketch how health systems and disparity research may advance maternal health equity by narrating, conceptualizing, and investigating social determinants of health as key drivers of perinatal disparity, by identifying the granular mechanism of this disparity, by making the economic case to address them, and by testing specific interventions to advance obstetric health equity. SUMMARY: Measuring social determinants of health and meaningful perinatal processes and outcomes precisely and accurately at the individual, family, community/neighborhood level is a prerequisite for healthcare disparity research. A focus on elucidating the precise mechanism driving disparity in processes of obstetric care would inform a more rational effort to promote health equity. Implementation scientists should rigorously investigate in prospective trials which countermeasures are most efficient and effective in mitigating perinatal outcome disparities.

Background Utilization of extracorporeal membrane oxygenation (ECMO) for adult critically ill patients is increasing, but data in obstetric cohorts are scant. This study analyzed ECMO utilization and maternal outcomes in obstetric patients in the United States. Methods Data were abstracted from the 1999-2014 National Inpatient Sample (NIS), a 20% US national representative sample. ECMO hospitalizations (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 39.65) in patients ≥15 years of age were categorized into obstetric ECMO and nonobstetric ECMO. Obstetric patients included 4 categories: (1) loss or termination of pregnancy, (2) delivery (term or preterm), (3) postdelivery hospitalization, and (4) pregnancy without an obstetrical outcome. Possible underlying causes for obstetric ECMO were identified by analysis of ICD-9-CM codes in individual records. In-hospital death was abstracted from the NIS, and ECMO complications were identified using ICD-9-CM algorithms. Statistical significance in time-effect was assessed using weighted regression models. Results During the 16-year study period, 20,454 adult ECMO cases were identified, of which 331 occurred in obstetric patients (1.6%; 95% confidence interval [CI], 1.4-1.8). Obstetric ECMO utilization rate was 4.7 per million obstetric discharges (95% CI, 4.2-5.2). The top 3 possible indications were sepsis (22.1%), cardiomyopathy (16.6%), and aspiration pneumonia (9.7%). Obstetric ECMO utilization rate increased significantly during the study period from 1.1 per million obstetric discharges in 1999-2002 (95% CI, 0.6-1.7) to 11.2 in 2011-2014 (95% CI, 9.6-12.9), corresponding to a 144.7% increase per 4-year period (95% CI, 115.3-178.1). Compared with nonobstetric ECMO, obstetric ECMO was associated with decreased in-hospital all-cause mortality (adjusted odds ratio [aOR] 0.78; 95% CI, 0.66-0.93). In-hospital all-cause mortality for obstetric ECMO decreased from 73.7% in 1999-2002 (95% CI, 48.8-90.8) to 31.9% in 2011-2014 (95% CI, 25.2-39.1), corresponding to a 26.1% decrease per 4-year period (95% CI, 10.1-39.3). Compared with nonobstetric ECMO, obstetric ECMO was associated with significantly increased risk of both venous thromboembolism without associated pulmonary embolism (aOR 1.83; 95% CI, 1.06-3.15) and of nontraumatic hemoperitoneum (aOR 4.32; 95% CI, 2.41-7.74). Conclusions During the study period, obstetric ECMO utilization has increased significantly and maternal prognosis improved.

Addressing severe maternal morbidity (SMM) is a public health priority in the US. Use of labor neuraxial analgesia for vaginal delivery is suggested to reduce the risk of postpartum hemorrhage (PPH), the leading cause of preventable severe maternal morbidity.To assess the association between the use of labor neuraxial analgesia for vaginal delivery and SMM.In this population-based cross-sectional study, women aged 15 to 49 years undergoing their first vaginal delivery were included. Data were taken from hospital discharge records from New York between January 2010 and December 2017. Data were analyzed from November 2020 to November 2021.Neuraxial analgesia (ie, epidural or combined spinal-epidural) vs no neuraxial analgesia.The primary outcome was SMM, as defined by the US Centers for Disease Control and Prevention, and the secondary outcome was PPH. Adjusted odds ratios (aORs) and 95% CIs of SMM associated with neuraxial analgesia were estimated using the inverse propensity score-weighting method and stratified according to race and ethnicity (non-Hispanic White vs racial and ethnic minority women, including non-Hispanic Asian or Pacific Islander, non-Hispanic Black, Hispanic, and other race and ethnicity) and to the comorbidity index for obstetric patients (low-risk vs high-risk women). The proportion of the association of neuraxial analgesia with the risk of SMM mediated through PPH was estimated using mediation analysis.Of 575 524 included women, the mean (SD) age was 28 (6) years, and 46 065 (8.0%) were non-Hispanic Asian or Pacific Islander, 88 577 (15.4%) were non-Hispanic Black, 104 866 (18.2%) were Hispanic, 258 276 (44.9%) were non-Hispanic White, and 74 534 (13.0%) were other race and ethnicity. A total of 400 346 women (69.6%) were in the low-risk group and 175 178 (30.4%) in the high-risk group, and 272 921 women (47.4%) received neuraxial analgesia. SMM occurred in 7712 women (1.3%), of which 2748 (35.6%) had PPH. Before weighting, the incidence of SMM was 1.3% (3486 of 272 291) with neuraxial analgesia compared with 1.4% (4226 of 302 603) without neuraxial analgesia (risk difference, -0.12 per 100; 95% CI, -0.17 to -0.07). After weighting, the aOR of SMM associated with neuraxial analgesia was 0.86 (95% CI, 0.82-0.90). Decreased risk of SMM associated with neuraxial analgesia was similar between non-Hispanic White women and racial and ethnic minority women and between low-risk and high-risk women. More than one-fifth (21%; 95% CI, 14-28) of the observed association of neuraxial analgesia with the risk of SMM was mediated through the decreased risk of PPH.Findings from this study suggest that use of neuraxial analgesia for vaginal delivery is associated with a 14% decrease in the risk of SMM. Increasing access to and utilization of labor neuraxial analgesia may contribute to improving maternal health outcomes.

Supplemental Digital Content is available in the text., BACKGROUND: Protecting first-line health care providers against work-related Coronavirus Disease 2019 (COVID-19) infection at the onset of the pandemic has been a crucial challenge in the United States. Anesthesiologists in particular are considered at risk, since aerosol-generating procedures, such as intubation and extubation, have been shown to significantly increase the odds for respiratory infections during severe acute respiratory syndrome (SARS) outbreaks. This study assessed the incidence of COVID-19–like symptoms and thepresence of COVID-19 antibodies after work-related COVID-19 exposures, among physicians working in a large academic hospital in New York City (NYC). METHODS: An e-mail survey was addressed to anesthesiologists and affiliated intensive care providers at Columbia University Irving Medical Center on April 15, 2020. The survey assessed 4 domains: (1) demographics and medical history, (2) community exposure to COVID-19 (eg, use of NYC subway), (3) work-related exposure to COVID-19, and (4) development of COVID-19–like symptoms after work exposure. The first 100 survey responders were invited to undergo a blood test to assess antibody status (presence of immunoglobulin M [IgM]/immunoglobulin G [IgG] specific to COVID-19). Work-related exposure was defined as any episode where the provider was not wearing adequate personal protective equipment (airborne or droplet/contact protection depending on the exposure type). Based on the clinical scenario, work exposure was categorized as highrisk (eg, exposure during intubation) or lowrisk (eg, exposure during doffing). RESULTS: Two hundred and five health care providers were contacted and 105 completed the survey (51%); 91 completed the serological test. Sixty-one of the respondents (58%) reported at least 1 work-related exposure and 54% of the exposures were highrisk. Among respondents reporting a work-related exposure, 16 (26.2%) reported postexposure COVID-19–like symptoms. The most frequent symptoms were myalgia (9 cases), diarrhea (8 cases), fever (7 cases), and sore throat (7 cases). COVID-19 antibodies were detected in 11 of the 91 tested respondents (12.1%), with no difference between respondents with (11.8%) or without (12.5%) a work-related exposure, including high-risk exposure. Compared with antibody-negative respondents, antibody-positive respondents were more likely to use NYC subway to commute to work and report COVID-19–like symptoms in the past90 days. CONCLUSIONS: In the epicenter of the United States’ pandemic and within 6–8 weeks of the COVID-19 outbreak, a small proportion of anesthesiologists and affiliated intensive care providers reported COVID-19–like symptoms after a work-related exposure and even fewer had detectable COVID-19 antibodies. Thepresenceof COVID-19 antibodies appeared to be associated with community/environmental transmission rather than secondary to work-related exposures involving high-risk procedures.

BACKGROUND:Increased risks of cerebral venous thrombosis or subdural hematoma, bacterial meningitis, persistent headache, and persistent low back pain are suggested in obstetric patients with postdural puncture headache (PDPH). Acute postpartum pain such as PDPH may also lead to postpartum depressio

ObjectiveTo analyse trends, risk factors, and outcomes related to hypertensive disorders of pregnancy (HDP).DesignRepeated cross-sectional.SettingUS delivery hospitalisations.PopulationDelivery hospitalisations in the 2000-2018National Inpatient Sample.MethodsUS hospital delivery hospitalisations with HDP were analysed. Several trends were analysed: (i) the proportion of deliveries by year with HDP, (ii) the proportion of deliveries with HDP risk factors and (iii) adverse outcomes associated with HDP including maternal stroke, acute renal failure and acute liver injury. Risk ratios were determined using regression models with HDP as the exposure of interest.Main outcome measuresPrevalence of HDP, risk factors for HDP and associated adverse outcomes.ResultsOf 73.1million delivery hospitalisations, 7.7% had an associated diagnosis of HDP. Over the study period, HDP doubled from 6.0% of deliveries in 2000 to 12.0% in 2018. The proportion of deliveries with risk factors for HDP increased from 9.6% in 2000 to 24.6% in 2018. In adjusted models, HDP were associated with increased stroke (aRR [adjusted risk ratio] 15.9, 95% CI 14.8-17.1), acute renal failure (aRR 13.8, 95% CI 13.5-14.2) and acute liver injury (aRR 1.2, 95% CI 1.2-1.3). Among deliveries with HDP, acute renal failure and acute liver injury increased; in comparison, stroke decreased.ConclusionHypertensive disorders of pregnancy increased in the setting of risk factors for HDP becoming more common, whereas stroke decreased.Tweetable abstractWhile hypertensive disorders of pregnancy increased from 2000 to 2018, stroke appears to be decreasing.

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

Background Medicaid expansions under the Affordable Care Act have increased insurance coverage and prenatal care utilization in low-income women. However, it is not clear whether they are associated with any measurable improvement in maternal health outcomes. In this study, we compared the changes in the incidence of severe maternal morbidity (SMM) during delivery hospitalizations between low- and high-income women associated with the 2014 Medicaid expansion in New York State. Methods Data for this retrospective cohort study came from the 2006-2016 New York State Inpatient Database, a census of discharge records from community hospitals. The outcome was SMM during delivery hospitalizations, as defined by the Centers for Disease Control and Prevention. We used regression coefficients (β) from multivariable logistic models: (1) to compare independently in low-income women and in high-income women the changes in slopes in the incidence of SMM before (2006-2013) and after (2014-2016) the expansion, and (2) to compare low- and high-income women for the changes in slopes in the incidence of SMM before and after the expansion. Results A total of 2,286,975 delivery hospitalizations were analyzed. The proportion of Medicaid beneficiaries in parturients increased a relative 12.1% (95% confidence interval [CI], 11.8-12.4), from 42.9% in the preexpansion period to 48.1% in the postexpansion period, whereas the proportion of the uninsured decreased a relative 4.8% (95% CI, 2.8-6.8). Multivariable logistic modeling revealed that implementation of the 2014 Medicaid expansion was associated with a decreased slope during the postexpansion period both in low-income women (β = -0.0161 or 1.6% decrease; 95% CI, -0.0190 to -0.0132) and in high-income women (β = -0.0111 or 1.1% decrease; 95% CI, -0.0130 to -0.0091). The decrease in slope during the postexpansion period was greater in low- than in high-income women (β = -0.0042 or 0.42% difference; 95% CI, -0.0076 to -0.0007). Conclusions Implementation of the Medicaid expansion in 2014 in New York State is associated with a small but statistically significant reduction in the incidence of SMM in low-income women compared with high-income women.

Racial and ethnic diversification of the physician and nurse workforce is recommended as a leverage point to address the impact of structural racism in maternal care, but empirical evidence supporting this recommendation is currently lacking.This study aimed to assess the association between state-level registered nurse workforce racial and ethnic diversity and severe adverse maternal outcomes during childbirth.This population-based cross-sectional study analyzed 2017 US birth certificate data. Severe adverse maternal outcomes included eclampsia, blood transfusion, hysterectomy, or intensive care unit admission. Proportions of minoritized racial and ethnic registered nurses in each state were abstracted from the American Community Survey (5-year estimate, 2013-2017). This proportion was categorized into 3 terciles, with the first tercile corresponding to the lowest proportion and the third tercile corresponding to the highest proportion. Crude and adjusted odds ratios and 95% confidence intervals of severe adverse maternal outcomes associated with terciles of the state proportion of minoritized racial and ethnic nurses were estimated using logistic regression models.Of the 3,668,813 birth certificates studied, 29,174 recorded severe adverse maternal outcomes (79.5 per 10,000; 95% confidence interval, 78.6-80.4). The mean state proportion of minoritized racial and ethnic nurses was 22.1%, ranging from 3.3% in Maine to 68.2% in Hawaii. For White mothers, the incidence of severe adverse outcomes was 85.3 per 10,000 for those who gave births in states in the first tercile of the proportion of minoritized racial and ethnic nurses and 53.9 per 10,000 for those who gave birth in states in the third tercile (risk difference, -31.4 per 10,000; 95% confidence interval, -34.4 to -28.5). It corresponds to a 37% decreased risk of severe adverse maternal outcomes associated with giving birth in a state in the third tercile (crude odds ratio, 0.63; 95% confidence interval, 0.60-0.66). A decreased risk of severe adverse maternal outcomes was observed for Black mothers (crude odds ratio, 0.65; 95% confidence interval, 0.61-0.70), Hispanic mothers (crude odds ratio, 0.51; 95% confidence interval, 0.48-0.54), and Asian and Pacific Islander mothers (crude odds ratio, 0.65; 95% confidence interval, 0.58-0.72) but not for Native American mothers (crude odds ratio, 0.89; 95% confidence interval, 0.72-1.09) or mothers with1 race (crude odds ratio, 1.44; 95% confidence interval, 0.72-1.09). After adjustment for patients and hospital characteristics, giving birth in states in the third tercile was associated with a reduced risk of severe adverse outcomes as follows: 32% for White mothers (adjusted odds ratio, 0.68; 95% confidence interval, 0.59-0.77), 20% for Black mothers (adjusted odds ratio, 0.80; 95% confidence interval, 0.65-0.99), 31% for Hispanic mothers (adjusted odds ratio, 0.69; 95% confidence interval, 0.58-0.82), and 50% for Asian and Pacific Islander mothers (adjusted odds ratio, 0.50; 95% confidence interval, 0.38-0.65). The associations of the proportion of minoritized racial and ethnic nurses with the risk of severe adverse maternal outcomes were not statistically significant for Native American mothers and more than 1 race mothers. Results were similar when blood transfusion was excluded from the outcome measure.A diverse state registered nurse workforce was associated with a reduced risk of severe adverse maternal outcomes during childbirth.

It is possible that in the setting of increasing patient comorbidity and obesity, risk for surgical injury and need for reoperation is increasing. It is also possible that with differential uptake of evidence-based recommendations and increasing prevalence of risk factors such as obesity, risk for surgical site complications is increasing. The objective of this study was to evaluate trends in, risk factors for, and racial disparities related to cesarean complications. This repeated cross-sectional study evaluated cesarean deliveries in the 2002–2014 National Inpatient Sample for women age 15–54. The primary outcome was a cesarean surgical complication composite including (i) surgical injuries, (ii) reoperation, and (iii) surgical site complications. Surgical injuries, reoperation, and surgical site complications were additionally evaluated individually as outcomes. Univariable and multivariable log linear regression models including demographic, clinical, and hospital factors were performed to assess risk for outcomes with unadjusted and adjusted risk ratios (aRR) with 95% confidence intervals (CI) as measures of association. Temporal trends were estimated using average annual percentage change from a joinpoint regression model. A stratified analysis was performed restricted to non-Hispanic black women. Data was weighted to provide national estimates. A total of 16.2 million estimated cesarean deliveries (3.2 million unweighted cesarean deliveries) from 2002 to 2014 were included in this analysis. The prevalence of the cesarean surgical complication composite was 1.14%, surgical site complications occurred in 0.60%, surgical injuries in 0.49%, and reoperations in 0.10%. Comparing the end of the study (2012–2014) to the beginning of the study (2002–2003), adjusted risk for the composite was similar (aRR 0.93, 95% CI 0.92, 0.95). In comparison, surgical site complication risk was lower at the end of the study (aRR 0.77, 95% CI 0.75, 0.79) while risks for surgical injury (aRR 1.18, 95% CI 1.15, 1.22) and reoperation (1.18, 95% CI 1.10, 1.26) were higher. Non-Hispanic black women were at increased risk for surgical site complications (aRR 1.83, 95% CI 1.80, 1.87) and reoperation (aRR 1.44, 95% CI 1.37, 1.51), but not surgical injury (aRR 0.99, 95% CI 0.97, 1.02). In analyses stratified for non-Hispanic black women, there was a reduction in risk for surgical site complications at the end of the study period compared to the beginning similar to the primary analysis (aRR 0.76, 95% 0.72, 0.81) with a modest decrease in overall risk for the composite outcome (aRR 0.85, 95% CI 0.81, 0.89). A decrease in risk for surgical site complications was offset by slightly increased risk for surgical injury and reoperation in adjusted analyses. Among non-Hispanic black women, surgical site complication risk decreased proportionately with this group still at significantly higher overall risk.

To analyze racial and ethnic disparities in failure to rescue (ie, death) associated with severe maternal morbidity and describe temporal trends.This was a retrospective cohort study using administrative data. Data for delivery hospitalizations with severe maternal morbidity, as defined by the Centers for Disease Control and Prevention, were abstracted from the 1999-2017 National Inpatient Sample. Race and ethnicity were categorized into non-Hispanic White (reference), non-Hispanic Black, Hispanic, other, and missing. The outcome was failure to rescue from severe maternal morbidity. Disparities were assessed using the failure-to-rescue rate ratio (ratio of the failure-to-rescue rate in the racial and minority group to the failure-to-rescue rate in White women), adjusted for patient and hospital characteristics. Temporal trends in severe maternal morbidity and failure to rescue were assessed.During the study period, 73,934,559 delivery hospitalizations were identified, including 993,864 with severe maternal morbidity (13.4/1,000; 95% CI 13.3-13.5). Among women with severe maternal morbidity, 4,328 died (4.3/1,000; 95% CI 4.2-4.5). The adjusted failure-to-rescue rate ratio was 1.79 (95% CI 1.77-1.81) for Black women, 1.39 (95% CI 1.37-1.41) for women of other race and ethnicity, 1.43 (95% CI 1.42-1.45) for women with missing race and ethnicity data, and 1.08 (95% CI 1.06-1.09) for Hispanic women. During the study period, the severe maternal morbidity rate increased significantly in each of the five racial and ethnic groups but started declining in 2012. Meanwhile, the failure-to-rescue rate decreased significantly during the entire study period.Despite improvement over time, failure to rescue from severe maternal morbidity remains a major contributing factor to excess maternal mortality in racial and ethnic minority women.

Background Previous research suggests that, compared with regional anesthesia, general anesthesia is associated with increased odds of postoperative depressive disorders. No study has specifically evaluated the possible protective effect of neuraxial anesthesia for cesarean delivery on maternal mental health compared with general anesthesia. This exploratory study was designed to test the hypothesis that general anesthesia for cesarean delivery is associated with increased odds of severe postpartum depression (PPD) requiring hospitalization compared with neuraxial anesthesia. Methods This retrospective cohort study included cesarean delivery cases performed in New York State hospitals between January 2006 and December 2013. Exclusion criteria were as follows: (1) having >1 cesarean delivery during the study period; (2) residing outside of New York State; (3) having a general anesthetic for other surgery or delivery in the previous year or in the year after the index case. The primary outcome was the occurrence of PPD, and the secondary outcomes were: (1) the composite of suicidal ideation or self-inflicted injury (ie, suicidality); (2) anxiety disorders; and (3) posttraumatic stress disorders (PTSD). Primary and secondary outcomes were identified during the delivery hospitalization and up to 1 year after delivery. Adjusted odds ratios (aORs) and 95% confidence interval (CI) of adverse psychiatric outcomes associated with general anesthesia were estimated using propensity score matching. Results Of the 428,204 cesarean delivery cases included, 34,356 had general anesthesia (8.0%). Severe PPD requiring hospitalization was recorded in 1158 women (2.7/1000; 95% CI, 2.5-2.9); of them, 60% were identified during readmission, with a median of 164 days after discharge. Relative to neuraxial anesthesia, general anesthesia in cesarean delivery was associated with a 54% increased odds of PPD (aOR, 1.54; 95% CI, 1.21-1.95) and a 91% increased odds of suicidal ideation or self-inflicted injury (aOR, 1.91; 95% CI, 1.12-3.25). There was insufficient evidence in these data that general anesthesia was associated with anxiety disorders (aOR, 1.37; 95% CI, 0.97-1.95) or PTSD (aOR, 1.50; 95% CI, 0.50-4.47). Conclusions General anesthesia for cesarean delivery is associated with increased odds of severe PPD requiring hospitalization, suicidal ideation, and self-inflicted injury. If confirmed, these preliminary findings underscore the need to avoid the use of general anesthesia for cesarean delivery whenever possible, and to provide mental health screening, counseling, and other follow-up services to obstetric patients exposed to general anesthesia.

IntroductionOpioid exposure during hospitalization for cesarean delivery increases the risk of new persistent opioid use. We studied the effectiveness of stepwise multimodal opioid-sparing analgesia in reducing oxycodone use during cesarean delivery hospitalization and prescriptions at discharge.MethodsThis retrospective cohort study analyzed electronic health records of consecutive cesarean delivery cases in four academic hospitals in a large metropolitan area, before and after implementation of a stepwise multimodal opioid-sparing analgesic computerized order set coupled with provider education. The primary outcome was the proportion of women not using any oxycodone during in-hospital stay (‘non-oxycodone user’). In-hospital secondary outcomes were: (1) total in-hospital oxycodone dose among users, and (2) time to first oxycodone pill. Discharge secondary outcomes were: (1) proportion of oxycodone-free discharge prescription, and (2) number of oxycodone pills prescribed.ResultsThe intervention was associated with a significant increase in the proportion of non-oxycodone users from 15% to 32% (17% difference; 95% CI 10 to 25), a decrease in total in-hospital oxycodone dose among users, and no change in the time to first oxycodone dose. The adjusted OR for being a non-oxycodone user associated with the intervention was 2.67 (95% CI 2.12 to 3.50). With the intervention, the proportion of oxycodone-free discharge prescription increased from 4.4% to 8.5% (4.1% difference; 95% CI 2.5 to 5.6) and the number of prescribed oxycodone pills decreased from 30 to 18 (−12 pills difference; 95% CI −11 to −13).ConclusionsMultimodal stepwise analgesia after cesarean delivery increases the proportion of oxycodone-free women during in-hospital stay and at discharge.

BACKGROUND: Labor neuraxial analgesia (LNA) utilization has increased in the United States but its impact on maternal safety is unknown. This study analyzed the temporal trends in the incidence of post-dural puncture headache (PDPH) in obstetrics. METHODS: Data for vaginal or intrapartum cesarean deliveries came from the National Inpatient Sample 2006–2015, an US 20% representative sample of hospital discharge records. The outcome was PDPH (ICD-9-CM codes 349.0 and 03.95) categorized into 1) PDPH coded as without epidural blood patch (EBP), and 2) PDPH coded as with EBP. Temporal trends in incidence were described using the percent change (PC) between 2006 and 2015 and its 95% confidence interval (CI). RESULTS: Of the 29,011,472 deliveries studied, 86,558 (29.8 per 10,000; 95% CI: 29.3, 30.2) recorded a diagnosis of PDPH, including 34,019 PDPH without EBP (11.7 per 10,000; 95% CI: 11.4, 12.0) and 52,539 PDPH with EBP (18.1 per 10,000; 95% CI: 17.8, 18.4). A statistically significant decrease in the incidence of PDPH was observed from 31.5 per 10,000 in 2006 to 29.2 per 10,000 in 2015 (PC −7.5%; 95% CI: −2.2, −0.5; P-value = 0.001). The decrease in the incidence of PDPH was statistically significant irrespective of the presence of EBP. The decrease was observed in the 3 categories of hospitals examined (rural, urban non-teaching, and urban teaching). CONCLUSIONS: During the study period, the reported incidence of PDPH in the United States has decreased modestly. Intervention programs are needed to address this persistent and preventable cause of maternal morbidity.

Background The incidence of severe maternal morbidity (SMM) during childbirth is increasing in the United States. A better characterization of risk factors for SMM may identify targets for improving maternal outcomes. This study aims to characterize patient-, hospital-, and neighborhood-level factors associated with SMM during childbirth. Methods SMM during childbirth was identified in the 2013-2014 State Inpatients Database for New York. Hospital and neighborhood characteristics were abstracted from the American Hospital Association and the Area Health Resources files. Multilevel modeling was used to identify factors associated with SMM, with and without blood transfusion, and its between-hospital variation. Results 403,116 delivery-related discharges from 139 hospitals were analyzed; 1557 (0.39%) recorded SMM without blood transfusion. In the final multilevel model, 7 patient-level factors were associated with a greater than fourfold increase in the risk of SMM: pulmonary hypertension, postpartum hemorrhage, placenta accreta, chronic kidney disease, cardiac conduction disorders, emergent cesarean delivery, and preeclampsia. Three hospital-level factors were associated with SMM: proportion of non-White patients, proportion of Medicaid beneficiaries, and coding intensity. No neighborhood-level factors were predictive of SMM. The proportion of variation in SMM explained by the model was 23.5 with 23.2% related to patient-level factors. The model explained 55% of the between-hospital variation, primarily related to patient-level factors. Similar results were observed for SMM with blood transfusion. Conclusions This study confirms the association between patient-level factors and SMM. It identifies patient-level factors as the major driver of between-hospital variation in SMM. Efforts to improve maternal outcomes should target patient-level factors.

Background The incidence of severe maternal morbidity is increasing in the United Sates. To improve maternal outcomes, three maternal complications have been selected for priority intervention based on their proportionate mortality and preventability: obstetric hemorrhage, severe hypertension, and venous thromboembolism. This approach excludes complications that are not associated with high mortality but significantly contribute to maternal morbidity. The aim of this study was to provide an alternative ranking of maternal complications requiring interventions using cost-based criticality analysis. Methods Discharge records indicating delivery hospitalizations, and 17 maternal complications were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes in the 2012 National Inpatient Sample, a 20% national representative sample of hospital discharge records from community hospitals. For each complication, criticality was calculated as the product of its incidence and severity. Severity was estimated using excess cost, the difference between the mean costs of discharges with and without the complication. Costs were calculated as the product of hospital charges and a cost-to-charge ratio and adjusted with a linear regression model. Complications were ranked based on criticality. Results The study sample included 734,865 delivery hospitalizations. At least one complication was recorded in 80,657 discharges (11.0%, 95% confidence interval = 10.9-11.1). The four highest-ranked critical complications were pre-eclampsia/eclampsia (criticality: $93), postpartum hemorrhage ($47), gestational hypertension ($34), and anesthesia-related complications ($5). Conclusions In addition to postpartum hemorrhage and severe hypertension, anesthesia-related complications and gestational hypertension may be new priority targets for interventions during delivery hospitalizations. Criticality analysis seems to be an alternative or complimentary approach for planning healthcare quality improvement programs.

BACKGROUND Need for critical care during delivery hospitalizations may be an important maternal outcome measure, but it is not well characterized. OBJECTIVE This study aimed to characterize the risks and disparities in critical care diagnoses and interventions during delivery hospitalizations. STUDY DESIGN This serial cross-sectional study used the 2000-2014 National Inpatient Sample. Here, the primary outcome was a composite of critical care interventions and diagnoses, including mechanical ventilation and intubation, central monitoring, septicemia, coma, acute cerebrovascular disease, extracorporeal membrane oxygenation, Swan-Ganz catheter monitoring, cardiac rhythm conversion, and respiratory failure. Temporal trends, risk of death, and the proportion of deaths with a critical care composite diagnosis were determined. Unadjusted and adjusted log-linear regression models were fit with a critical care composite as the outcome, adjusting for demographic, clinical, and hospital factors. To evaluate the role of critical care interventions in disparities, analyses were stratified by maternal race and ethnicity. RESULTS Of 45.8 million deliveries identified, 0.21% had a critical care procedure or diagnosis during the delivery hospitalization. Overall, 75.8% of maternal deaths had an associated diagnosis from a critical care composite. The critical composite increased from 17.9 to 30.3 per 10,000 deliveries from 2000 to 2014 with an average annual percentage change of 3.4% (95% confidence interval, 1.3-5.5). Mechanical ventilation and intubation (21.5% of cases) and respiratory failure (54.8% of cases) were the most common diagnoses present in the composite. Although non-Hispanic black women were at 32.4% higher risk than non-Hispanic white women to die in the setting of a critical care diagnosis (2.2% vs 1.7%; P

BACKGROUND:Socioeconomic deprivation is associated with reduced use of antenatal resources and poor maternal outcomes with pregnancy. Research examining the association between socioeconomic deprivation and use of obstetric anesthesia care in a country providing universal health coverage is scarce.

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Compared with neuraxial anesthesia, general anesthesia for cesarean delivery is associated with increased risk of maternal adverse events. Reducing avoidable general anesthetics for cesarean delivery may improve safety of obstetric anesthesia care. This study examined adverse events, trends, and factors associated with potentially avoidable general anesthetics for cesarean delivery. Methods This retrospective study analyzed cesarean delivery cases without a recorded indication for general anesthesia or contraindication to neuraxial anesthesia in New York State hospitals, 2003 to 2014. Adverse events included anesthesia complications (systemic, neuraxial-related, and drug-related), surgical site infection, venous thromboembolism, and the composite of death or cardiac arrest. Anesthesia complications were defined as severe if associated with death, organ failure, or prolonged hospital stay. Results During the study period, 466,014 cesarean deliveries without a recorded indication for general anesthesia or contraindication to neuraxial anesthesia were analyzed; 26,431 were completed with general anesthesia (5.7%). The proportion of avoidable general anesthetics decreased from 5.6% in 2003 to 2004 to 4.8% in 2013 to 2014 (14% reduction; P < 0.001). Avoidable general anesthetics were associated with significantly increased risk of anesthesia complications (adjusted odds ratio, 1.6; 95% CI, 1.4 to 1.9), severe complications (adjusted odds ratio, 2.9; 95% CI, 1.6 to 5.2), surgical site infection (adjusted odds ratio, 1.7; 95% CI, 1.5 to 2.1), and venous thromboembolism (adjusted odds ratio, 1.9; 95% CI, 1.3 to 3.0), but not of death or cardiac arrest. Labor neuraxial analgesia rate was one of the most actionable hospital-level factors associated with avoidable general anesthetics. Relative to hospitals with a rate greater than or equal to 75%, the adjusted odds ratio of avoidable general anesthetics increased to 1.3 (95% CI, 1.2 to 1.4), 1.6 (95% CI, 1.5 to 1.7), and 3.2 (95% CI, 3.0 to 3.5) as the rate decreased to 50 to 74.9%, 25 to 49.9%, and less than 25%, respectively. Conclusions Compared with neuraxial anesthesia, avoidable general anesthetics are associated with increased risk of adverse maternal outcomes.

Objectives This study examined the prevalence and temporal trends in (a) pulmonary hypertension (PH) during pregnancy and (b) mortality and morbidity during pregnancy with and without PH. Methods This was a retrospective observational study of the 2003–2014 New York State Inpatient Database. PH was categorized as primary or secondary and pregnancy as loss or termination of pregnancy, preterm birth, or term birth. The Centers for Disease Control and Prevention definition of maternal morbidity was used, including 17 diagnoses and 5 procedures. Changes were assessed using Cochran-Armitage trend tests. Results Of 2,940,868 pregnancy-related discharges, 746 indicated a diagnosis of PH (25/100,000; 95% CI 24–27). PH was secondary in 677/746 (91%) discharges and 488/746 were term births (65%). Prevalence of secondary PH increased from 17 to 30/100,000 between 2003– 2004 and 2013–2014 (+ 69%; P

The safety of anesthetic care provided during childbirth has improved during the past 2 decades in the United States, with a marked decrease in the rate of anesthesia-related adverse events (ARAEs). To date, there is little research on the costs of ARAEs in obstetrics. This study aims to assess the excess cost and cost per admission associated with ARAEs during labor and delivery.Data came from the New York State Inpatient Database 2010. Discharge records indicating labor and delivery and ARAEs were identified with International Classification of Diseases, Ninth Revision, Clinical Modification codes. ARAEs were defined as minor if not associated with maternal death, cardiac arrest, or severe morbidity. Costs were calculated as the product of hospital charges and the group average all-payer inpatient charge-to-cost conversion ratio. Excess cost was calculated as the difference between the mean cost of discharges with and without ARAEs. The cost per admission was calculated as the product of the excess cost and ARAE incidence. Excess costs and cost per admission were also calculated for 2 pregnancy-related complications: postpartum hemorrhage and preeclampsia/eclampsia.There were 228,104 delivery-related discharges in the study; of these, 1053 recorded at least 1 ARAE (4.6 per 1000), with 1034 (98.2%) of the ARAEs being minor. The adjusted excess cost associated with ARAEs was $1189 (95% confidence interval [CI], 1033-1350) and the cost per admission $5.49 (95% CI, 4.77-6.23). The incidence of postpartum hemorrhage and preeclamspia/eclampsia was 25.1 and 43.8 per 1000, respectively. The adjusted excess cost was $679 (95% CI, 608-748) and $1328 (95% CI, 1272-1378), respectively; the cost per admission was $17.07 (95% CI, 15.27-18.81) and $58.16 (95% CI, 55.72-60.34), respectively.ARAEs during labor and delivery are associated with significant excess cost. However, the excess cost per admission for ARAEs is significantly less compared with the excess cost per admission for preeclampsia/eclampsia and postpartum hemorrhage.

BACKGROUND: Pruritus is a common side effect of intrathecal fentanyl or sufentanil that decreases patient satisfaction and may delay hospital discharge. There are conflicting reports about the efficacy of prophylactic ondansetron in reducing the incidence of pruritus. This meta-analysis aimed to assess the effect of prophylactic ondansetron on the incidence of intrathecal fentanyl- or sufentanil-mediated pruritus and the need for rescue treatment. METHODS: A systematic search on PubMed, Medline, and the Cochrane Central Register of Controlled Trials from January 1, 1994, to January 1, 2014, was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Randomized controlled trials evaluating the efficacy of prophylactic ondansetron on pruritus associated with intrathecal fentanyl or sufentanil were included. The primary outcome was the incidence of pruritus, and the secondary outcome was patients’ need for rescue therapy. Sensitivity analyses were conducted to assess the outcomes in obstetric and nonobstetric patients and in patients who received ondansetron before or after intrathecal opioid injection. Analyses used random-effect models. RESULTS: Six randomized controlled trials involving 555 patients were included. In the overall analysis, prophylactic ondansetron did not significantly decrease the incidence of pruritus, but there was a trend toward reduced rescue medication use (risk ratio [RR], 0.57; 95% confidence interval [CI], 0.35–0.91; I2 = 0%; P = 0.02). Exploratory subgroups, including nonobstetric surgery patients and patients who received ondansetron before spinal opioid administration, also suggest a trend toward less rescue medication use (RR, 0.47; 95% CI, 0.26–0.85; P = 0.01; and RR, 0.62; 95% CI, 0.38–1.00; P = 0.05). CONCLUSIONS: IV 8 mg prophylactic ondansetron does not decrease the incidence of fentanyl- or sufentanil-mediated pruritus but may decrease the need for pruritus rescue medication, particularly in specific subgroups. Randomized trials are needed to confirm these results.

Background: Individual assessment of the amplitude of a physiologic reflex evoked by a standardized noxious test (SNT) before surgical stimulation has been suggested to predict movement upon the forthcoming surgical stimulation. This study aimed to compare the ability of pupillary dilatation reflex amplitude (PDRA) evoked by an SNT and estimated remifentanil effect-site concentration (Ce) to predict movement upon surgical stimulation. Methods: Eighty female patients were anesthetized for vacuum aspiration with propofol (Ce 4 μg/ml) and remifentanil. Remifentanil Ce was randomized to 0, 1, 3, or 5 ng/ml. SNT was a 60-mA, 5-s, 100-Hz tetanus applied on median nerve before cervix dilatation. PDRA was calculated as the difference in pupillary diameter after and before SNT. Movement upon cervix dilatation was recorded by an independent observer. Ability of PDRA and estimated remifentanil Ce to discriminate movers from non-movers during cervix dilatation was measured as the area under the receiver operating characteristics curve. Results: Twenty-one of the 76 patients analyzed moved during cervix dilatation. Mean PDRA (±1 SD) evoked by SNT was 2.0 ± 1.2 mm in movers and 0.6 ± 0.7 in non-movers (P < 0.0001). Remifentanil Ce was 0.2 ± 0.4 ng/ml in movers and 3.0 ± 1.7 in non-movers (P < 0.0001). Area under the receiver operating characteristics curve for PDRA was 0.90 (95% CI, 0.83 to 0.96) and for remifentanil Ce 0.94 (0.89 to 0.98), without any significant difference between the two areas. Conclusions: PDRA evoked by an SNT is as accurate as the estimated remifentanil Ce to predict movement upon cervix dilatation. PDRA could be valuable when estimated opioid Ce is not available or reliable.

Importance Identification of risk factors for adverse obstetrical outcomes after appendectomy and cholecystectomy during pregnancy is necessary for evidence-based risk reduction and adequate patient counseling. Objectives To identify risk factors for adverse obstetrical outcomes after appendectomy and cholecystectomy during pregnancy and stratify the risk of such outcomes. Design, Setting, and Participants A cohort study was conducted using the Nationwide Inpatient Sample, a nationally representative sample of patients discharged from community hospitals in the United States, from January 1, 2003, to December 31, 2012. Multivariable analysis of risk factors for adverse obstetric outcomes was performed for 19 926 women undergoing appendectomy or cholecystectomy during pregnancy and a scoring system for such risk factors was developed. Data analysis was conducted from January 1, 2015, to July 31, 2016. Main Outcomes and Measures A composite measure including 7 adverse obstetrical outcomes throughout pregnancy and occurring before hospital discharge. Results Of the 19 926 women (mean [SD] age, 26 [6] years) in the study, 1018 adverse obstetrical events were recorded in 953 pregnant women (4.8%). The 3 most frequent adverse events were preterm delivery (360 [35.4%]), preterm labor without preterm delivery (269 [26.4%]), and miscarriage (262 [25.7%]). The risk factors associated most strongly with an adverse obstetrical outcome included cervical incompetence (adjusted odds ratio, 24.29; 95% CI, 7.48-78.81), preterm labor during current pregnancy (adjusted odds ratio, 18.34; 95% CI, 4.95-67.96), vaginitis or vulvovaginitis (adjusted odds ratio, 5.17; 95% CI, 2.19-12.23), and sepsis (adjusted odds ratio, 3.39; 95% CI, 2.08-5.51). A scoring system based on statistically significant variables classified the study sample into 3 risk groups corresponding to predicted probabilities of adverse obstetrical outcomes of 2.5% (≤4 points), 8.2% (5-8 points), and 21.8% (≥9 points). Conclusions and Relevance Approximately 5% of women experience adverse obstetrical outcomes after appendectomy or cholecystectomy during pregnancy. The major risk factors for such outcomes are cervical incompetence, preterm labor during current pregnancy, vaginitis or vulvovaginitis, and sepsis.

Resume Plusieurs etudes ont suggere que le monitorage de la profondeur de l’anesthesie permettait de reduire la consommation d’agents anesthesiques et eventuellement la morbidite/mortalite postoperatoire. Ces resultats, bien que discutes, ont donne lieu a l’etude d’impact du monitorage de la pression arterielle, de la profondeur d’anesthesie par l’indice bispectral (BIS) et de la concentration en halogenes lors de l’entretien de l’anesthesie, sur la mortalite distance de l’anesthesie. Les resultats qui montrent que des valeurs basses de ces trois variables sont associees avec un risque accru de mortalite sont discutes dans cet article ainsi que leur pertinence clinique.

Background Marfan's syndrome is characterized by progressive dilatation of the aortic root. This dilatation is accelerated by pregnancy, exposing patients to an increased risk of aortic dissection. Literature on the anesthetic management of delivery in patients with Marfan's syndrome consists only of case reports. We therefore conducted a retrospective review of medical records focusing on anesthetic management of delivery in patients with Marfan's syndrome in a national referral center. Methods We reviewed the medical records of all pregnant women with Marfan's syndrome who were followed at their institution over a 6-year period. Results Sixteen pregnancies in 15 patients were analyzed. The initial aortic root diameter was larger than 40 mm in 9 patients and larger than 45 mm in 1 patient. Two patients did not receive β-blockers throughout pregnancy because of poor tolerance. One patient with an aortic root diameter of 47 mm did not receive β-blocker before 33 weeks' gestation because of late referral. This woman developed acute type 1 aortic dissection at 37 weeks, requiring emergency cesarean delivery under general anesthesia followed by aortic repair. Thirteen other patients underwent cesarean delivery, 1 under spinal anesthesia and 12 under general anesthesia. General anesthesia management included close arterial blood pressure monitoring, avoidance of high blood pressure, administration of opioids before delivery, and titrated nicardipine administration. Two patients (including one with intrauterine fetal death) underwent vaginal delivery under epidural analgesia. There were no maternal deaths. Conclusions Pregnant women with Marfan's syndrome who received care in a multidisciplinary tertiary care setting that included active peripartum involvement of anesthesiologists had good clinical outcomes.

Marked variation across hospitals in adverse maternal outcomes in cesarean deliveries is reported, including anesthesia-related adverse events (ARAEs). Identification of hospital-level characteristics accounting for this variation may help guide interventions to improve anesthesia care quality. In this study, we examined the association between hospital-level characteristics and ARAEs in cesarean deliveries and assessed individual hospital performance.Discharge records for cesarean deliveries, ARAEs, and patient characteristics in the State Inpatient Database for New York State 2009 to 2011 were identified with International Classification of Diseases, Ninth Revision, Clinical Modification codes. The hospital reporting index was calculated as the sum of International Classification of Diseases, Ninth Revision, Clinical Modification codes divided by the number of discharges. Data on hospital characteristics were obtained from the American Hospital Association and the Area Health Resources files. Multilevel modeling was used to examine the association of hospital-level characteristics with ARAEs and to assess individual hospital performance.The study included 236,960 discharges indicating cesarean deliveries in 141 hospitals; 1557 discharges recorded at least 1 ARAE (6.6 per 1000; 95% confidence interval [CI], 6.2-6.9). The following factors were associated with a significantly increased risk of ARAEs: Charlson comorbidity index ≥ 1 (adjusted odds ratio [aOR], 1.2), multiple gestation (aOR, 1.3), postpartum hemorrhage (aOR, 1.5), general anesthesia (aOR, 1.3), hospital annual cesarean delivery volume200 (aOR, 2.3), and reporting index (aOR, 1.1 per 1 increase per discharge). Fifteen percent of the between-hospital variation in ARAEs was explained by the hospital annual cesarean delivery volume and 6% by the reporting index. Eight hospitals (6%) were classified as good-performing, 104 (74%) as average-performing, and 29 (21%) as bad-performing hospitals. Compared with good-performing hospitals, a 2.3-fold (95% CI, 1.7-3.0) and 5.9-fold (95% CI, 4.5-7.8) increase in the rate of ARAEs was observed in average- and bad-performing hospitals, respectively. Bringing up bad-performing hospitals to the level of average-performing hospitals would prevent 466 ARAEs (30%).Low cesarean delivery volume is the strongest hospital-level predictor of ARAEs in cesarean deliveries and the main determinant of between-hospital variation. Future study to identify other factors and interventions to improve performance in bad-performing hospitals is warranted.

Background De-escalation is strongly recommended for antibiotic stewardship. No studies have addressed this issue in the context of health care-associated intra-abdominal infections (HCIAI). We analyzed the factors that could interfere with this process and their clinical consequences in intensive care unit (ICU) patients with HCIAI. Methods All consecutive patients admitted for the management of HCIAI who survived more than 3 days following their diagnosis, who remained in the ICU for more than 3 days, and who did not undergo early reoperation during the first 3 days were analyzed prospectively in an observational, single-center study in a tertiary care university hospital. Results Overall, 311 patients with HCIAI were admitted to the ICU. De-escalation was applied in 110 patients (53 %), and no de-escalation was reported in 96 patients (47 %) (escalation in 65 [32 %] and unchanged regimen in 31 [15 %]). Lower proportions of Enterococcus faecium, nonfermenting Gram-negative bacilli (NFGNB), and multidrug-resistant (MDR) strains were cultured in the de-escalation group. No clinical difference was observed at day 7 between patients who were de-escalated and those who were not. Determinants of de-escalation in multivariate analysis were adequate empiric therapy (OR 9.60, 95 % CI 4.02–22.97) and empiric use of vancomycin (OR 3.39, 95 % CI 1.46–7.87), carbapenems (OR 2.64, 95 % CI 1.01–6.91), and aminoglycosides (OR 2.31 95 % CI 1.08–4.94). The presence of NFGNB (OR 0.28, 95 % CI 0.09–0.89) and the presence of MDR bacteria (OR 0.21, 95 % CI 0.09–0.52) were risk factors for non-de-escalation. De-escalation did not change the overall duration of therapy. The risk factors for death at day 28 were presence of fungi (HR 2.64, 95 % CI 1.34–5.17), Sequential Organ Failure Assessment score on admission (HR 1.29, 95 % CI 1.16–1.42), and age (HR 1.03, 95 % CI 1.01–1.05). The survival rate expressed by a Kaplan-Meier curve was similar between groups (log-rank test p value 0.176). Conclusions De-escalation is a feasible option in patients with polymicrobial infections such as HCIAI, but MDR organisms and NFGNB limit its implementation.

Background Chronic stress during pregnancy has been associated with worsened maternal and fetal outcomes. Acute stress immediately before spinal anaesthesia for caesarean section may contribute to hypotension. Therefore objective measures of acute stress may help identify women at risk of adverse outcomes. Salivary alpha-amylase is a stress biomarker that has so far been poorly investigated during pregnancy. The reference change value is the difference between two sequential results that must be exceeded for a change to be considered clinically relevant. Our first aim was to determine if salivary alpha-amylase increased in pregnant patients when subjected to the stress of transfer to the operating room. Our second aim was to determine if changes in salivary alpha-amylase were likely to be clinically significant by measuring reference change value in healthy volunteers. Methods In 15 pregnant patients undergoing planned caesarean section under spinal anaesthesia, salivary alpha-amylase, systolic blood pressure, heart rate, and immediate anxiety were measured on the morning of surgery on the ward and again in the operating room. The reference change value was calculated from 18 healthy volunteers. Results A median 220% increase in salivary alpha-amylase activity ( P =0.0015) and a 17% increase in systolic blood pressure ( P =0.0006) were observed between the ward and operating room. No changes of immediate anxiety or heart rate were observed. Reference change value was ±76% in volunteers and 13 of the 15 pregnant patients had a salivary alpha-amylase increase greater than the reference change value. Conclusion When pregnant women are taken to the operating room, a clinically and statistically significant increase in salivary alpha-amylase was observed. Further studies are required to define its clinical usefulness.

Background Cesarean delivery (CD) is associated with significantly increased risks of anesthesia-related adverse events (ARAEs) and nonanesthetic perioperative morbidity compared with vaginal delivery. Temporal trends in these adverse outcomes remain unknown despite efforts to improve maternal safety. This study examines temporal trends in ARAEs and nonanesthetic perioperative complications in CDs in New York hospitals. Methods Data are from the State Inpatient Database for New York, 2003–2012. ARAEs, including minor and major ARAEs, and nonanesthetic perioperative complications were identified through International Classification of Diseases, Ninth Revision, Clinical Modification codes. Statistical significance in time trends was assessed using the Cochran–Armitage test and multivariable logistic regression. Results Of the 785,854 CDs studied, 5,715 (730 per 100,000; 95% CI, 710 to 750) had at least one ARAE and 7,040 had at least one perioperative complication (890 per 100,000; 95% CI, 870 to 920). The overall annual rate of ARAEs decreased from 890 per 100,000 in 2003 to 660 in 2012 (25% decrease; 95% CI, 16 to 34; P < 0.0001). The rate of minor ARAEs decreased 23% (95% CI, 13 to 32) and of major ARAEs decreased 43% (95% CI, 23 to 63). No decrease was observed in the rate of ARAEs for CDs performed under general anesthesia. The rate of nonanesthetic complications increased 47% (95% CI, 31 to 63; P < 0.0001). Conclusions Anesthesia-related outcomes in cesarean deliveries appear to have improved significantly across hospitals in New York in the past decade. Perioperative nonanesthetic complications remain a serious healthcare issue.

Resume Le transfert transplacentaire des agents de l’anesthesie s’effectue par diffusion. L’ensemble des agents a l’exception des curares diffuse facilement. Ce passage expose le nouveau-ne au risque de depression neonatale qui peut etre prevenu par le respect des regles d’administration de ces agents. Toutefois, les consequences du passage transplacentaire des agents anesthesique sur le nouveau-ne ne doivent pas occulter celles des effets maternels des agents de l’anesthesie sur le fœtus et notamment de l’hypotension maternelle.

Background: The rate of anesthesia-related adverse events (ARAEs) is recommended for monitoring patient safety across hospitals. To ensure comparability, it is adjusted for patients’ characteristics with logistic models (i.e., risk adjustment). The rate adjusted for patient-level characteristics and hospital affiliation through multilevel modeling is suggested as a better metric. This study aims to assess a multilevel model-based rate of ARAEs. Methods: Data were obtained from the State Inpatient Database for New York 2008–2011. Discharge records for labor and delivery and ARAEs were identified with International Classification of Diseases, Ninth Revision, Clinical Modification codes. The rate of ARAEs for each hospital during 2008–2009 was calculated using both the multilevel and the logistic modeling approaches. Performance of the two methods was assessed with (1) interhospital variability measured by the SD of the rates; (2) reclassification of hospitals; and (3) prediction of hospital performance in 2010–2011. Rankability of each hospital was assessed with the multilevel model. Results: The study involved 466,442 discharge records in 2008–2009 from 144 hospitals. The overall observed rate of ARAEs in 2008–2009 was 4.62 per 1,000 discharges [95% CI, 4.43 to 4.82]. Compared with risk adjustment, multilevel modeling decreased SD of ARAE rates from 4.7 to 1.3 across hospitals, reduced the proportion of hospitals classified as good performers from 18% to 10%, and performed similarly well in predicting future ARAE rates. Twenty-six hospitals (18%) were nonrankable due to inadequate reliability. Conclusion: The multilevel modeling approach could be used as an alternative to risk adjustment in monitoring obstetric anesthesia safety across hospitals.

International audience; BACKGROUND:Prognostic research studies in anesthesiology aim to identify risk factors for an outcome (explanatory studies) or calculate the risk of this outcome on the basis of patients' risk factors (predictive studies). Multivariable models express the relationship between predictors and an outcome and are used in both explanatory and predictive studies. Model development demands a strict methodology and a clear reporting to assess its reliability. In this methodological descriptive review, we critically assessed the reporting and methodology of multivariable analysis used in observational prognostic studies published in anesthesiology journals.METHODS:A systematic search was conducted on Medline through Web of Knowledge, PubMed, and journal websites to identify observational prognostic studies with multivariable analysis published in Anesthesiology, Anesthesia & Analgesia, The British Journal of Anaesthesia, and Anaesthesia in 2010 and 2011. Data were extracted by 2 independent readers. First, studies were analyzed with respect to reporting of outcomes, design, size, methods of analysis, model performance (discrimination and calibration), model validation, clinical usefulness, and STROBE (i.e., Strengthening the Reporting of Observational Studies in Epidemiology) checklist. A reporting rate was calculated on the basis of 21 items of the aforementioned points. Second, they were analyzed with respect to some predefined methodological points.RESULTS:Eighty-six studies were included: 87.2% were explanatory and 80.2% investigated a postoperative event. The reporting was fairly good, with a median reporting rate of 79% (75% in explanatory studies and 100% in predictive studies). Six items had a reporting rate

Background. Dysfunction of the cough reflex as a result of the lingering effects of anaesthetics may lead to aspiration pneumonia or retained secretions after general anaesthesia. It is unknown whether low concentrations of propofol alter the cough reflex in the early period after anaesthesia. The objective of this study was to investigate the effect of low concentrations of propofol on the cough reflex sensitivity as assessed by the cough reflex threshold to an inhaled irritant. Methods.Fifteen,ASAI‐II,non-smokingpatientsundergoingelectivecolonoscopywerestudied. Anaesthesia was induced and maintained with a blood target-controlled propofol infusion. Cough reflex threshold was measured with citric acid. Increasing concentrations of nebulized citric acid (2.5, 5, 10, 20, 40, 80, 160, 320, and 640 mg ml 1 ) were delivered during inspiration until a cough wasevoked.Thecitric acid concentrationeliciting onecough(C1) wasdefinedas thecoughreflex threshold. C1 was log transformed for statistical analysis (Log C1). Log C1 was measured before anaesthesia and during the recovery period with estimated decreasing propofol concentrations of 1.2, 0.9, 0.6, and 0.3 m gm l 1 . Results. Log C1 (median; interquartile range) measured with propofol concentrations of 1.2, 0.9, 0.6, 0.3, and 0 m gm l 1 were 1.9 (0.6), 1.9 (1.0), 1.9 (1.1), 1.9 (0.6), and 1.9 (0.7) mg ml 1 (NS), respectively. However, light sedation was observed with propofol concentrations of 1.2 and 0.9 m gm l 1 . Conclusion. This study indicates that residual sedation after propofol anaesthesia for colonoscopy does not adversely affect the cough reflex. Br J Anaesth 2005; 95: 406‐9

Objective: Postoperative hyponatremia is a frequent metabolic disturbance that may cause life-threatening complications. It results from both a positive electrolyte-free water (EFW) balance and an antidiuretic hormone release. During surgery, intracellular solutes may leak out of cells because of an increased membrane permeability leading to increased osmolality, cellular water shift, and redistribution hyponatremia, a concept coined the sick cell syndrome. Because of release of osmotically active solutes, plasma or urinary osmolar gap should increase. Therefore, we tested the hypothesis that postoperative hyponatremia may be related to a translocational mechanism evidenced by a postoperative increase of the osmolar gap rather than to a positive EFW balance. Setting: An anesthesiology department in a 1,200-bed university hospital. Design: A 5-month prospective observational study. Subjects: Thirty-three consecutive patients undergoing elective hip arthroplasty under general anesthesia. They were divided into two groups whether the postoperative plasma sodium concentration decrease was ≥2 mmol/L (group 1) or