Publications by authors named "Mark A Clapp"

34 Publications

Derivation and external validation of risk stratification models for severe maternal morbidity using prenatal encounter diagnosis codes.

J Perinatol 2021 May 19. Epub 2021 May 19.

Center for Quantitative Health, Massachusetts General Hospital, Boston, MA, USA.

Objective: We sought to develop a prediction model using prenatal diagnosis codes that could help clinicians objectively stratify a women's risk for delivery-related morbidity.

Study Design: We performed a prospective cohort study of women delivering at a single academic medical center between 2016 and 2019. Diagnosis codes from outpatient encounters were extracted from the electronic health record. Standard and common machine-learning methods for variable selection were compared. The performance characteristics from the selected model in the training data set-a LASSO model with a lambda that minimized the Bayes information criteria-were compared in a testing and external validation set.

Results: The model identified a group of women, those in the highest decile of predicted risk, who were at a two to threefold increased risk of maternal morbidity.

Conclusion: As EHR data becomes more ubiquitous, other data types generated from the prenatal period may improve the model's performance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41372-021-01072-zDOI Listing
May 2021

Outcomes of the First Pregnancy After Fertility-Sparing Surgery for Early-Stage Ovarian Cancer.

Obstet Gynecol 2021 06;137(6):1109-1118

Department of Gynecologic Oncology and Reproductive Medicine, the Department of Health Services Research, Division of Cancer Prevention and Population Sciences, and the Department of Breast Medical Oncology, the University of Texas MD Anderson Cancer Center, Houston, Texas; the Department of Obstetrics and Gynecology, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts; the Department of Obstetrics and Gynecology, the University of Texas Medical Branch at Galveston, Galveston, Texas; and the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, and the Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York.

Objective: To evaluate the outcomes of the first pregnancy after fertility-sparing surgery in patients treated for early-stage ovarian cancer.

Methods: We performed a retrospective study of women aged 18-45 years with a history of stage IA or IC ovarian cancer reported to the California Cancer Registry for the years 2000-2012. These data were linked to the 2000-2012 California Office of Statewide Health Planning and Development birth and discharge data sets to ascertain oncologic characteristics and obstetric outcomes. We included in the case group ovarian cancer patients who conceived at least 3 months after fertility-sparing surgery. The primary outcome was preterm birth, and only the first pregnancy after cancer diagnosis was considered. Secondary outcomes included small-for-gestational-age (SGA) neonates, neonatal morbidity (respiratory support within 72 hours after birth, hypoxic-ischemic encephalopathy, seizures, infection, meconium aspiration syndrome, birth trauma, and intracranial or subgaleal hemorrhage), and severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Propensity scores were used to match women in a 1:2 ratio for the case group and the control group. Wald statistics and logistic regressions were used to evaluate outcomes.

Results: A total of 153 patients who conceived after fertility-sparing surgery were matched to 306 women in a control group. Histologic types included epithelial (55%), germ-cell (37%), and sex-cord stromal (7%). Treatment for ovarian cancer was not associated with preterm birth before 37 weeks of gestation (13.7% vs 11.4%; odds ratio [OR] 1.23, 95% CI 0.69-2.20), SGA neonates (birth weight less than the 10th percentile: 11.8% vs 12.7%; OR 0.91, 95% CI 0.50-1.66), severe maternal morbidity (2.6% vs 1.3%; OR 2.03, 95% CI 0.50-8.25), or neonatal morbidity (both 5.9% OR 1.00, 95% CI 0.44-2.28).

Conclusion: Patients who conceived at least 3 months after surgery for early-stage ovarian cancer did not have an increased risk of adverse obstetric outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AOG.0000000000004394DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141030PMC
June 2021

The use of a validated obstetrical risk score for maternal morbidity to predict postpartum hemorrhage for women in labor.

Am J Obstet Gynecol 2021 Apr 23. Epub 2021 Apr 23.

Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA; Department of Population Medicine, Harvard Medical School, Boston, MA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajog.2021.04.243DOI Listing
April 2021

Comparison of Maternal and Neonatal Subspecialty Care Provision by Hospital.

Am J Perinatol 2021 Apr 20. Epub 2021 Apr 20.

Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts.

Objective:  The aim of the study is to determine the relationship between a hospital's provision of subspecialty neonatal and maternal care. Specifically, we sought to understand where women with high-risk maternal conditions received intrapartum care and estimate the potential transfer burden for those with maternal high-risk conditions delivering at hospitals without subspecialty maternal care.

Study Design:  This is a descriptive study using data from 2015 State Inpatient Databases and the American Hospital Association Annual Survey. Characteristics were compared between hospitals based on the concordance of their maternal and neonatal care. The incidences of high-risk maternal conditions (pre-eclampsia with severe features, placenta previa with prior cesarean delivery, cardiac disease, pulmonary edema, and acute liver failure) were compared. To determine the potential referral burden, the percent of women with high-risk conditions delivering at a hospital without subspecialty maternal care but delivering in a county with a hospital with subspecialty maternal care was calculated.

Results:  The analysis included 486,398 women who delivered at 544 hospitals, of which 104 (19%) and 182 (33%) had subspecialty maternal and neonatal care, respectively. Ninety-eight hospitals provided both subspecialty maternal and neonatal care; however, 84 hospitals provided only subspecialty neonatal care but no subspecialty maternal care. Among high-risk maternal conditions examined, approximately 65% of women delivered at a hospital with subspecialty maternal care. Of the remainder who delivered at a hospital without subspecialty maternal care, one-third were in a county where subspecialty care was present. For women with high-risk conditions who delivered in a county without subspecialty maternal care, the median distance to the closest county with subspecialty care was 52.8 miles (IQR 34.3-87.7 miles).

Conclusion:  Approximately 50% of hospitals with subspecialty neonatal care do not provide subspecialty maternal care. This discordance may present a challenge when both high-risk maternal and neonatal conditions are present.

Key Points: · High-risk women who deliver at hospitals without subspecialty care are in more rural areas.. · Approximately 50% of hospitals with subspecialty neonatal care do not provide subspecialty maternal care.. · This discordance may present a challenge when both high-risk maternal and neonatal conditions are present..
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0041-1727223DOI Listing
April 2021

Incidence of and Risk Factors for Failed Induction of Labor Using a Contemporary Definition.

Obstet Gynecol 2021 Mar;137(3):497-504

Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Objective: To estimate the incidence of failed induction of labor and the associated patient risk factors.

Methods: We performed a case-control study from a cohort of nulliparous women who delivered between 39 and 41 weeks of gestation after an induction of labor in one of seven hospitals. Cases of failed induction were defined using the Obstetric Care Consensus criteria (ie, cesarean delivery performed in early labor [less than 6 cm dilatation] after at least 12 hours of oxytocin administration from membrane rupture). For each case of failed induction, the next four women who did not meet the criteria for failed induction of labor were selected for the control group, matched by hospital. We identified characteristics associated with failed induction of labor using a multivariable conditional logistic regression that was constructed with backward stepwise method for variable selection.

Results: Across the hospitals, 4,123 of 10,175 nulliparous women were induced (40.5%), of whom 82 had a failed induction of labor (2.0%). A total of 328 women were selected for the matched control group. Baseline characteristics were similar between the groups. Compared with women in the control group, women with a failed induction were more likely to have a delivery body mass index (BMI) of 40 or higher (28.0 vs 8.2%, P<.001), shorter height (mean 63.9 vs 64.8 inches, P=.01), and closed cervix on admission (41.5 vs 24.1%, P=.002). Factors significantly associated with induction failure in the multivariable model included: 1) delivery BMI (adjusted odds ratio [aOR] 7.93, 95% CI 3.48-18.09, for BMI 40 or higher relative to BMI lower than 30, 2) height in inches (aOR 0.89, 95% CI 0.80-0.98), and 3) number of centimeters dilated on admission 2 or more (aOR 0.30, 95% CI 0.14-0.65).

Conclusion: Failed induction of labor occurs infrequently. Risk factors include shorter height, BMI 40 or higher, and cervical dilatation of less than 2 cm on admission. Even so, most women with these risk factors will not experience failed labor induction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AOG.0000000000004257DOI Listing
March 2021

The utility of electronic health record data for identifying postpartum hemorrhage.

Am J Obstet Gynecol MFM 2021 03 6;3(2):100305. Epub 2021 Jan 6.

Center for Quantitative Health, Division of Clinical Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajogmf.2020.100305DOI Listing
March 2021

Identification of Delivery Encounters Using International Classification of Diseases, Tenth Revision, Diagnosis and Procedure Codes.

Obstet Gynecol 2020 10;136(4):765-767

Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts; and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AOG.0000000000004099DOI Listing
October 2020

Calculating the Cost of Elective 39-Week Induction.

Obstet Gynecol 2020 07;136(1):6-7

Drs. Clapp and Ecker are from the Department of Obstetrics and Gynecology, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts; email:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AOG.0000000000003957DOI Listing
July 2020

Patient and Hospital Factors Associated With Unexpected Newborn Complications Among Term Neonates in US Hospitals.

JAMA Netw Open 2020 02 5;3(2):e1919498. Epub 2020 Feb 5.

Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston.

Importance: Unexpected complications in term newborns have been recently adopted by the Joint Commission as a marker of obstetric care quality.

Objective: To understand the variation and patient and hospital factors associated with severe unexpected complications in term neonates among hospitals in the United States.

Design, Setting, And Participants: This cross-sectional study collected data from all births in US counties with 1 obstetric hospital using county-identified birth certificate data and American Hospital Association annual survey data from January 1, 2015, through December 31, 2017. All live-born, term, singleton infants weighing at least 2500 g were included. The data analysis was performed from December 1, 2018, through June 30, 2019.

Exposures: Severe unexpected newborn complication, defined as neonatal death, 5-minute Apgar score of 3 or less, seizure, use of assisted ventilation for at least 6 hours, or transfer to another facility.

Main Outcomes And Measures: Between-hospital variation and patient and hospital factors associated with unexpected newborn complications.

Results: A total of 1 754 852 births from 576 hospitals were included in the analysis. A wide range of hospital complication rates was found (range, 0.6-89.9 per 1000 births; median, 15.3 per 1000 births [interquartile range, 9.6-22.0 per 1000 births]). Hospitals with high newborn complication rates were more likely to care for younger, white, less educated, and publicly insured women with more medical comorbidities compared with hospitals with low complication rates. In the adjusted models, there was little effect of case mix to explain the observed between-county variation (11.3%; 95% CI, 10.0%-12.6%). Neonatal transfer was the primary factor associated with complication rates, especially among hospitals with the highest rates (66.0% of all complications). The risk for unexpected neonatal complication increased by more than 50% for those neonates born at hospitals without a neonatal intensive care unit compared with those with a neonatal intensive care unit (adjusted odds ratio, 1.55; 95% CI, 1.38-1.75).

Conclusions And Relevance: In this study, severe unexpected complication rates among term newborns varied widely. When included in the metric numerator, neonatal transfer was the primary factor associated with complications, especially among hospitals with the highest rates. Transfers were more likely to be necessary when infants were born in hospitals with lower levels of neonatal care. Thus, if this metric is to be used in its current form, it would appear that accreditors, regulatory bodies, and payers should consider adjusting for or stratifying by a hospital's level of neonatal care to avoid disincentivizing against appropriate transfers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamanetworkopen.2019.19498DOI Listing
February 2020

Fragmentation of postpartum readmissions in the United States.

Am J Obstet Gynecol 2020 08 18;223(2):252.e1-252.e14. Epub 2020 Jan 18.

Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York. Electronic address:

Background: Fragmentation of care, wherein a patient is readmitted to a hospital different from the initial point of care, has been shown to be associated with worse patient outcomes in other medical specialties. However, postpartum fragmentation of care has not been well characterized in obstetrics.

Objective: To characterize risk for and outcomes associated with fragmentation of postpartum readmissions wherein the readmitting hospital is different than the delivery hospital.

Methods: The 2010 to 2014 Nationwide Readmissions Database was used for this retrospective cohort study. Postpartum readmissions within 60 days of delivery hospitalization discharge for women aged 15-54 years were identified. The primary outcome, fragmentation, was defined as readmission to a different hospital than the delivery hospital. Hospital, demographic, medical, and obstetric factors associated with fragmented readmission were analyzed. Adjusted log-linear models were performed to analyze risk for readmission with adjusted risk ratios and 95% confidence intervals as the measures of effect. The associations between fragmentation and secondary outcomes including (1) length of stay >90th percentile, (2) hospitalization costs >90th percentile, and (3) severe maternal morbidity were determined. Whether specific indications for readmission such as hypertensive diseases of pregnancy, wound complications, and other conditions were associated with higher or lower risk for fragmentation was analyzed.

Results: From 2010 to 2014, 141,276 60-day postpartum readmissions were identified, of which 15% of readmissions (n = 21,789) occurred at a hospital different from where the delivery occurred. Evaluating individual readmission indications, fragmentation was less likely for hypertension (11.1%), wound complications (10.7%), and uterine infections (11.0%), and more likely for heart failure (28.6%), thromboembolism (28.4%), and upper respiratory infections (33.9%) (P < .01 for all). In the adjusted analysis, factors associated with fragmentation included public insurance compared to private insurance (Medicare: adjusted risk ratio, 1.68; 95% confidence interval, 1.52, 1.86; Medicaid: adjusted risk ratio, 1.28; 95% confidence interval, 1.24, 1.32). Fragmentation was associated with increased risk for severe maternal morbidity during readmissions in both unadjusted (relative risk, 1.84; 95% confidence interval, 1.79, 1.89) and adjusted (adjusted risk ratio, 1.81; 95% confidence interval, 1.76, 1.86) analyses. In adjusted analyses, fragmentation was also associated with increased risk for length of stay >90th percentile (relative risk, 1.48; 95% confidence interval, 1.42-1.54) and hospitalization costs >90th percentile (adjusted risk ratio, 1.74; 95% confidence interval, 1.67, 1.81).

Conclusion: This study of nationwide estimates of postpartum fragmentation found discontinuity of postpartum care was associated with increased risk for severe morbidity, high costs, and long length of stay. Reduction of fragmentation may represent an important goal in overall efforts to improve postpartum care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajog.2020.01.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7367706PMC
August 2020

Outpatient Expectant Management of Term Prelabor Rupture of Membranes: A Retrospective Cohort Study.

Am J Perinatol 2021 Jun 31;38(7):714-720. Epub 2019 Dec 31.

Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts.

Objective:  To examine outcomes among women with prelabor rupture of membranes (PROM) who declined induction and chose outpatient expectant management compared with those admitted for induction.

Study Design:  This is a retrospective cohort study of term women with singleton, vertex-presenting fetuses who presented with PROM between July 2016 and June 2017 and were eligible for outpatient expectant management ( = 166). The primary outcomes were time from PROM to delivery and time from admission to delivery. Maternal and neonatal outcomes were also compared between groups. Multivariable linear regressions were used to assess time differences between groups, adjusting for known maternal and pregnancy characteristics.

Results:  Compared with admitted patients, women managed expectantly at home had significantly longer PROM to delivery intervals (median 29.2 vs. 17 hours,  < 0.001), but were more likely to deliver within 24 hours of admission (95.1 vs. 82.9%,  = 0.004). In the adjusted analysis, PROM to delivery was 7 hours longer (95% confidence interval [CI]: 3.9-10.0) and admission to delivery was 5.3 hours shorter (95% CI: 2.8-7.7) in the outpatient expectant management cohort. There were no differences in secondary outcomes.

Conclusion:  Outpatient management of term PROM is associated with longer PROM to delivery intervals, but shorter admission to delivery intervals.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0039-3400997DOI Listing
June 2021

Low Fetal Fraction and Birth Weight in Women with Negative First-Trimester Cell-Free DNA Screening.

Am J Perinatol 2020 01 18;37(1):86-91. Epub 2019 Nov 18.

Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts.

Objective: To determine the association between low fetal fraction and birth weight among women with a negative cell-free DNA (cfDNA) result for common aneuploidies in the first trimester.

Study Design: This is a retrospective cohort of women who delivered a singleton between July 2016 and June 2018 at a single institution and had normal cfDNA testing in the first trimester. The primary variable of interest was "low fetal fraction," which was defined as fetal fractions less than 5th percentile among all fetal fractions in the cohort (fetal fraction < 5.34%). The primary outcomes were birth weight ≤ 5th and ≤ 10th percentiles. Multivariable logistic regressions assessed for the association between low fetal fraction and birth weight.

Results: A total of 7,478 women delivered a singleton at ≥24 weeks' gestation, of which 2,387 (32%) underwent genetic screening through cfDNA; the majority were in the first trimester ( = 2,052 [86%]). 2,035 met the inclusion criteria. Birth weight ≤ 5th percentile was significantly higher in the low fetal fraction group (6.9 vs. 3.2%;  = 0.04). A low fetal fraction was associated with higher odds of an infant with a low birth weight: adjusted odds ratio (aOR) of 2.32 (95% CI 1.15-4.67) for birth weight ≤ 10th percentile ( = 0.02) and aOR of 3.73 (95% CI 1.40-9.03) for birth weight ≤ 5th percentile ( = 0.004).

Conclusion: Low fetal fractions of ≤ 5th percentile were associated with an increased risk of birth weights ≤ 5th and ≤ 10th percentiles in women with negative cfDNA screening in the first trimester. Future work is needed to further investigate this relationship and to determine the potential clinical implications, such as third-trimester screening for growth restriction in women with low fetal fractions and negative cfDNA screening results.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0039-1700860DOI Listing
January 2020

Association of Medicaid Expansion With Coverage and Access to Care for Pregnant Women.

Obstet Gynecol 2019 11;134(5):1066-1074

Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, and the Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts; and the Department of Health Policy & Management, Columbia University Mailman School of Public Health, New York, New York.

Objective: To identify the association of the Affordable Care Act's Medicaid expansion with payment for delivery, early access to prenatal care, preterm birth, and birth weights considered small for gestational age (SGA).

Methods: A difference-in-difference design was used to assess changes in outcomes before and after Medicaid expansion in expansion states, using nonexpansion states as a control group. We used national birth certificate data from 2009 to 2017. Difference-in-difference linear probability models were used to assess the effects of the policy implementation, adjusting for demographics, month of birth, state, year, and county-level unemployment rates. Standard errors were clustered at the state level. Two prespecified subgroup analyses were performed of nulliparous women and women with no more than a high school diploma.

Results: The study sample included 8,701,889 women from 15 expansion states and 9,509,994 from 11 nonexpansion states. In the adjusted analysis, the percentage of Medicaid-covered deliveries increased by 2.3 absolute percentage points (95% CI 0.2-4.4, P=.04) in expansion states compared with nonexpansion states. There were no significant changes in the proportion of women who were uninsured, as there was a relative decrease in the percentage of deliveries covered by private insurance (-2.8 percentage points [95% CI -4.9 to -0.8, P=.01]). There were also no significant differences in the rate of women initiating prenatal care in the first trimester, preterm birth rates, or rates of low birth weight after the Medicaid expansion. Findings were similar in both subgroups.

Conclusion: Medicaid expansion was associated with increased Medicaid coverage for childbirth in expansion states; similar gains in private coverage were seen in nonexpansion states. There were no associations with changes in early access to prenatal care, preterm birth, or SGA birth weights.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AOG.0000000000003501DOI Listing
November 2019

Oxytocin Compared to Buccal Misoprostol for Induction of Labor after Term Prelabor Rupture of Membranes.

Am J Perinatol 2021 02 6;38(3):224-230. Epub 2019 Sep 6.

Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts.

Objective: This study was aimed to determine if admission-to-delivery times vary between term nulliparous women with prelabor rupture of membranes (PROM) who initially receive oxytocin compared with buccal misoprostol for labor induction.

Study Design: This is a retrospective cohort of 130 term, nulliparous women with PROM and cervical dilation of ≤2 cm who underwent induction of labor with intravenous oxytocin or buccal misoprostol. The primary outcome was time from admission to delivery. Linear regressions with log transformation were used to estimate the effect of induction agent on time to delivery.

Results: Women receiving oxytocin had faster admission-to-delivery times than women receiving misoprostol (16.9 vs. 19.9 hours,  = 0.013). There were no significant differences in secondary outcomes between the groups. In the adjusted model, women who received misoprostol had a 22% longer time from admission to delivery (95% CI 5.0-42.0%) compared with women receiving oxytocin.

Conclusion: In term nulliparous patients with PROM, intravenous oxytocin is associated with faster admission-to-delivery times than buccal misoprostol.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0039-1696642DOI Listing
February 2021

High Fetal Fraction on First Trimester Cell-Free DNA Aneuploidy Screening and Adverse Pregnancy Outcomes.

Am J Perinatol 2020 01 31;37(1):8-13. Epub 2019 Jul 31.

Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts.

Objective: To test the hypothesis that high fetal fraction (FF) on first trimester cell-free deoxyribonucleic acid (cfDNA) aneuploidy screening is associated with adverse perinatal outcomes.

Study Design: This is a single-institution retrospective cohort study of women who underwent cfDNA screening at <14 weeks' gestation and delivered a singleton infant between July 2016 and June 2018. Women with abnormal results were excluded. Women with high FF (≥95th percentile) were compared with women with normal FF (5th-95th percentiles). Outcomes investigated were preterm birth, small for gestational age, and hypertensive disorders of pregnancy.

Results: A total of 2,033 women met inclusion criteria. The mean FF was 10.0%, and FF >16.5% was considered high ( = 102). Women with high FF had a greater chance of delivering a small for gestational age infant
Conclusion: Women with a high FF in the first trimester are at increased risk of delivering a small for gestational age infant
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0039-1694005DOI Listing
January 2020

Unexpected term NICU admissions: a marker of obstetrical care quality?

Am J Obstet Gynecol 2019 04 17;220(4):395.e1-395.e12. Epub 2019 Feb 17.

Departments of Obstetrics and Gynecology and Pediatrics, Massachusetts General Hospital, and Harvard Medical School, Harvard University, Boston, MA.

Background: Unexpected admissions of term neonates to the neonatal intensive care unit and unexpected postnatal complications have been proposed as neonatal-focused quality metrics for intrapartum care. Previous studies have noted significant variation in overall hospital neonatal intensive care unit admission rates; however, little is known about the influence of obstetric practices on these rates or whether variation among unanticipated admissions in low-risk, term neonates can be attributed to systemic hospital practices.

Objective: The objective of the study was to examine the relative effects of patient characteristics and intrapartum events on unexpected neonatal intensive care unit admissions and to quantify the between-hospital variation in neonatal intensive care unit admission rates among this group of neonates.

Study Design: We performed a retrospective cross-sectional study using data collected as part of the Consortium for Safe Labor study. Women who delivered term (≥37 weeks), singleton, nonanomalous, liveborn infants without an a priori risk for neonatal intensive care unit admission were included. The primary outcome was neonatal intensive care unit admission among this population. Multilevel mixed-effect models were used to calculate adjusted odds ratios for demographics (age, race, insurer), pregnancy characteristics (parity, gestational age, tobacco use, birthweight), maternal comorbidities (chronic and pregnancy-induced hypertension), hospital characteristics (delivery volume, hospital and neonatal intensive care unit level, academic affiliation), and intrapartum events (prolonged second stage, induction of labor, trial of labor after cesarean delivery, chorioamnionitis, meconium-stained amniotic fluid, and abruption). Intraclass correlation coefficients were used to estimate the between-hospital variance in a series of hierarchical models.

Results: Of the 143,951 infants meeting all patient and hospital inclusion criteria, 7995 (5.6%) were admitted to the neonatal intensive care unit after birth. In the fully adjusted model, the factors associated with the highest odds for neonatal intensive care unit admission included: nulliparity (adjusted odds ratio, 1.62 [95% confidence interval, 1.53-1.71]), large for gestational age (adjusted odds ratio, 1.59 [95% confidence interval, 1.47-1.71]), and small for gestational age (adjusted odds ratio, 1.60 [95% confidence interval, 1.47-1.73]). Induction of labor (adjusted odds ratio, 0.95 [95% confidence interval, 0.89-1.01]) was not associated with increased odds of neonatal intensive care unit admission compared with women who labored spontaneously. The events associated with higher odds of neonatal intensive care unit admission included: prolonged second stage (adjusted odds ratio, 1.66 [95% confidence interval, 1.51-1.83]); chorioamnionitis (adjusted odds ratio, 3.89 [95% confidence interval, 3.42-4.44]), meconium-stained amniotic fluid (adjusted odds ratio, 1.96 [95% confidence interval, 1.82-2.10]), and abruption (adjusted odds ratio, 2.64 [95% confidence interval, 2.16-.21]). Compared with women who did not labor, the odds of neonatal intensive care unit admission were lower for women who labored: adjusted odds ratio, 0.48 (95% confidence interval, 0.45-0.52) for women with no uterine scar and adjusted odds ratio, 0.83 (95% confidence interval, 0.73-0.94) for women with a uterine scar. There was significant variation in neonatal intensive care unit admission rates by hospital, ranging from 2.9% to 11.2%. After accounting for case mix and hospital characteristics, the between-hospital variance was 1.9%, suggesting that little of the variation was explained by the effect of the hospital.

Conclusion: This study contributes to the currently limited understanding of term, neonatal intensive care unit admission rates as a marker of obstetrical care quality. We demonstrated that significant variation exists in hospital unexpected neonatal intensive care unit admission rates and that certain intrapartum events are associated with an increased risk for neonatal intensive care unit admission after delivery. However, the between-hospital variation was low. Unmeasured confounders and extrinsic factors, such as neonatal intensive care unit bed availability, may limit the ability of unexpected term neonatal intensive care unit admissions to meaningfully reflect obstetrical care quality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajog.2019.02.001DOI Listing
April 2019

Using Cervical Dilation to Predict Labor Onset: A Tool for Elective Labor Induction Counseling.

Am J Perinatol 2019 12 29;36(14):1485-1491. Epub 2019 Jan 29.

Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Objective: To evaluate whether cervical dilation predicts the timing and likelihood of spontaneous labor at term.

Study Design: This was a retrospective cohort of nulliparous women with singleton pregnancies who delivered at term from 2013 to 2015. Outpatient cervical examinations performed after 37 weeks and prior to labor onset were collected. Survival analysis was used to analyze time to spontaneous labor with cervical dilation as the primary predictor, modeled as continuous and categorical variables (<1 cm, 1 cm, >1 cm).

Results: Our cohort included 726 women; 407 (56%) spontaneously labored, 263 (36%) were induced, and 56 (8%) had an unlabored cesarean delivery. Women with >1-cm dilation were three times more likely to spontaneously labor (adjusted hazard ratio [aHR]: 3.1; 95% confidence interval [CI]: 2.4-4) than those with <1-cm dilation. At 39 weeks, 60% of women with >1-cm dilation went into spontaneous labor as compared with only 28% of those with <1-cm dilation (aHR: 2.9; 95% CI: 2-4.4).

Conclusion: In our cohort of nulliparous women at term, those with cervical dilation > 1 cm were significantly more likely to go into labor in the following week. This information can aid in counseling about elective induction of labor.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0039-1677866DOI Listing
December 2019

Preconception insurance and initiation of prenatal care.

J Perinatol 2019 02 13;39(2):300-306. Epub 2018 Dec 13.

Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA.

Objective: The primary objective was to determine the association between preconception insurance and initiation of prenatal care.

Study Design: This retrospective cohort uses data from the Pregnancy Risk Assessment Monitoring System (2009-2013). Self-reported preconception insurance status was the primary exposure. The primary outcome was first trimester initiation of prenatal care. Secondary outcomes included: preterm delivery, birth weight, and the presence of birth defects. Survey-weighted generalized linear models were used to calculate risk ratios and accounted for state-level clustering.

Results: Of the 181,675 included women from 32 states, 21.1% were uninsured prior to conception. 88% of insured women vs. 70% of uninsured women initiated care in the first trimester. Uninsured women were less likely to initiate care in the first trimester (adjusted relative risk (RR) 0.87 (95% confidence interval 0.85-0.89), p < 0.001) compared to women with insurance in the adjusted analysis. Among the secondary outcomes, uninsured nulliparous women had a 20% higher risk of extremely (<28 weeks) preterm delivery than those with preconception insurance (adjusted RR 1.20 (1.03-1.39), p = 0.01). Uninsured women also had a slightly increased risk of having SGA infant compared to insured women (adjusted RR 1.04 (1.01-1.09), p = 0.02). There were no differences in the other secondary outcomes.

Conclusions: Preconception insurance is associated with earlier initiation of prenatal care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41372-018-0292-7DOI Listing
February 2019

Preconception Coverage Before and After the Affordable Care Act Medicaid Expansions.

Obstet Gynecol 2018 12;132(6):1394-1400

Deborah Kelly Center for Outcomes Research, Department of Obstetrics and Gynecology, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts; and the Department of Health Policy & Management, Columbia University Mailman School of Public Health, New York, New York.

Objective: To estimate the effects of the Affordable Care Act Medicaid expansion provision that was largely implemented in 2014 on preconception insurance coverage among low-income women.

Methods: We used a quasiexperimental, difference-in-difference design to compare changes in preconception insurance coverage among low-income women living in expansion compared with nonexpansion states before and after the Medicaid expansions. Women with family incomes 138% the federal poverty level or less who participated in the Pregnancy Risk Assessment Monitoring System from 2009 to 2015 from states that did or did not expand their Medicaid programs on January 1, 2014, were included. The exposure of interest was the state Medicaid expansion. The primary outcome was insurance status 1 month before conception. We conducted additional subgroup and sensitivity analyses to test the assumptions of the model and the robustness of the findings.

Results: The study sample included 30,495 women from eight states that expanded Medicaid under the Affordable Care Act and 26,561 patients from seven states in that did not. The rate of preconception Medicaid coverage was 30.8% prepolicy and 35.6% postpolicy in nonexpansion states and 43.2% prepolicy and 56.8% postpolicy in expansion states. There was a significantly greater increase in Medicaid coverage in expansion states after the policy implementation (adjusted difference-in-difference estimate +8.6% points, 95% CI 1.1-16.0). Rates of preconception uninsurance were 44.2% prepolicy and 34.3% postpolicy in nonexpansion states and 37.4% prepolicy and 23.5% postpolicy in expansion states. There was no significant difference in the changes in uninsurance between the two groups in the postpolicy period (adjusted difference-in-difference estimate -4.1, 95% CI -11.1 to 2.9). Non-Medicaid insurance coverage was 25.3% prepolicy and 30.5% postpolicy in nonexpansion states and 19.4% prepolicy and 19.7% postpolicy in expansion states. Relative to nonexpansion states, there was a significant decrease in non-Medicaid coverage in the expansion states in the postpolicy period (adjusted difference-in-difference estimate -4.7, 95% CI -8.3 to -1.1). The results were robust to alternate model specifications and study period definitions.

Conclusion: Medicaid expansion was associated with increased enrollment in Medicaid before pregnancy among low-income women; however, there were no changes in the rates of uninsurance. Additional years of postpolicy data are needed to fully assess the effects of the policy change.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AOG.0000000000002972DOI Listing
December 2018

Practice Variation in Antenatal Steroid Administration for Anticipated Late Preterm Birth: A Physician Survey.

Am J Perinatol 2019 01 17;36(2):200-204. Epub 2018 Jul 17.

Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina.

Objective: The objective of this study was to measure knowledge and practice variation in late preterm steroid use.

Study Design: Electronic survey of American College of Obstetricians and Gynecologists (ACOG) members about data supporting the ACOG/Society for Maternal-Fetal Medicine (SMFM) recommendations and practice when caring for women with anticipated late preterm birth (PTB), 34 to 36 weeks.

Results: Of 352 administered surveys, we obtained 193 completed responses (55%); 82.5% were generalist obstetrician-gynecologists (OB/GYNs), and 42% cared for women with anticipated late PTB at least weekly. Most believed that late preterm steroids provided benefit by reducing respiratory distress syndrome (93%), transient tachypnea of the newborn (83%), and neonatal intensive care unit admission (82%). More than half administered late preterm steroids to women with multiple gestations (73%), and pregestational diabetes (55-80%) depending on glycemic control. OB/GYNs administered steroids to insulin-dependent and poorly controlled diabetics more often than MFMs (75 vs. 46% and 59 vs. 37% respectively,  < 0.05 for both). While providers believed there was increased maternal hyperglycemia (88%) and neonatal hypoglycemia (59%), 88% believed neonatal respiratory benefits outweighed these risks. Respondents agreed research is needed to determine who are appropriate candidates (77%) and how to minimize adverse outcomes (82%).

Conclusion: Most providers are administering late preterm steroids to all women, even those populations who have been excluded from previous trials. Despite widespread use, providers believe more research is needed to optimize management.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0038-1667028DOI Listing
January 2019

Effects of mitochondrial disease/dysfunction on pregnancy: A retrospective study.

Mitochondrion 2019 05 7;46:214-220. Epub 2018 Jul 7.

MitoAction, PO Box 51474, Boston, MA 02205, United States.

A retrospective survey assessed the gynecologic, obstetric and fertility history of 103 women with mitochondrial disease (MD)/dysfunction (Md) aged 16 to 75 who had previously been pregnant. Most participants (34%) had a mitochondrial myopathy and there were 248 combined pregnancies with live deliveries (average 3.6 pregnancies/woman). In general, pregnancy in those with MD/Md appears to exacerbate some constitutional and neurological symptoms and may be more frequently associated with common obstetric complications, but this did not appear to result in worse pregnancy outcomes. Most women carried their pregnancy to term, but their neonates tended to have more congenital anomalies than expected.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.mito.2018.06.007DOI Listing
May 2019

Liposomal Bupivacaine Block at the Time of Cesarean Delivery to Decrease Postoperative Pain: A Randomized Controlled Trial.

Obstet Gynecol 2018 07;132(1):70-78

Division of Maternal-Fetal Medicine and the Deborah Kelly Center for Outcomes Research, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts; Providence Anesthesia Services, Spokane, Washington; and the Department of Anesthesia, Critical Care, and Pain Medicine and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, and the Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Objective: To evaluate whether a liposomal bupivacaine incisional block decreases postoperative pain and represents an opioid-minimizing strategy after scheduled cesarean delivery.

Methods: In a single-blind, randomized controlled trial among opioid-naive women undergoing cesarean delivery, liposomal bupivacaine or placebo was infiltrated into the fascia and skin at the surgical site, before fascial closure. Using an 11-point numeric rating scale, the primary outcome was pain score with movement at 48 hours postoperatively. A sample size of 40 women per group was needed to detect a 1.5-point reduction in pain score in the intervention group. Pain scores and opioid consumption, in oral morphine milligram equivalents, at 48 hours postoperatively were summarized as medians (interquartile range) and compared using the Wilcoxon rank-sum test.

Results: Between March and September 2017, 249 women were screened, 103 women enrolled, and 80 women were randomized. One woman in the liposomal bupivacaine group was excluded after randomization as a result of a vertical skin incision, leaving 39 patients in the liposomal bupivacaine group and 40 in the placebo group. Baseline characteristics between groups were similar. The median (interquartile range) pain score with movement at 48 hours postoperatively was 4 (2-5) in the liposomal bupivacaine group and 3.5 (2-5.5) in the placebo group (P=.72). The median (interquartile range) opioid use was 37.5 (7.5-60) morphine milligram equivalents in the liposomal bupivacaine group and 37.5 (15-75) morphine milligram equivalents in the placebo group during the first 48 hours postoperatively (P=.44).

Conclusion: Compared with placebo, a liposomal bupivacaine incisional block at the time of cesarean delivery resulted in similar postoperative pain scores in the first 48 hours postoperatively.

Clinical Trial Registration: ClinicalTrials.gov, NCT02959996.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AOG.0000000000002649DOI Listing
July 2018

The relative effects of patient and hospital factors on postpartum readmissions.

J Perinatol 2018 07 24;38(7):804-812. Epub 2018 May 24.

Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA.

Objective: To determine the relative effects of patient and hospital factors on a hospital's postpartum readmission rate.

Study Design: This retrospective cohort study was conducted using State Inpatient Databases from California, Florida, and New York between 2004 and 2013. We compared patient and hospital characteristics among hospitals with low and high readmission rates using χ tests. Risk-adjusted 30-day readmission rates were calculated for patient, delivery, and hospital characteristics to understand factors affecting readmission using fixed and random effects models.

Results: Patients in hospitals with low readmission rates were more likely to be white, to have private insurance and higher incomes, and to have fewer comorbidities. The patient comorbidities with the highest risk-adjusted readmission rates included hypertension (range, 2.14-3.04%), obesity (1.78-2.94%), preterm labor/delivery (2.50-2.60%), and seizure disorder (1.78-3.35%). Delivery complications were associated with increased risk-adjusted readmission rates. Compared to patient characteristics, hospital characteristics did not have a profound impact on readmission risk.

Conclusion: Obstetric readmissions were more attributable to patient and demographic characteristics than to hospital characteristics. Readmission metric-based incentives may ultimately penalize hospitals providing high-quality care due to patient characteristics specific to their catchment area.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41372-018-0125-8DOI Listing
July 2018

The effect of hospital acuity on severe maternal morbidity in high-risk patients.

Am J Obstet Gynecol 2018 07 16;219(1):111.e1-111.e7. Epub 2018 Apr 16.

Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.

Background: In 2015, the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists published guidelines that established levels of maternal care. These guidelines outlined the nursing, provider, and facility requirements for hospitals to be designated a birthing center or 1 of 4 levels of care. To date, these levels of maternal care have not been adopted widely; currently, no data exist on how these designations may affect maternal or neonatal outcomes.

Objective: Because the levels of maternal care attempt to reflect a hospital's ability to treat patients with certain conditions that are associated with increased risk of complications, our objective was to compare outcomes among high- and low-risk patients between high- and low-acuity hospitals. We hypothesized that hospitals that cared for a high rate of high-risk patients, which we considered "high-acuity" centers, would have a lower risk of severe maternal morbidity among high-risk patients compared with low-acuity centers.

Study Design: Deliveries were identified in the 2013 Nationwide Readmission Database. A patient's comorbidity index was assigned based on diagnosis and procedure codes with the use of previously validated methods; a comorbidity index of ≥3 has been associated with increased odds of severe maternal morbidity. Patients were classified as low, intermediate, or high risk by their comorbidity index for analysis. Patients at hospitals with <100 deliveries per year and transferred patients were excluded. A hospital was defined as low or high-acuity if it was in the bottom or top quartile, respectively, based on its percent of patients with a comorbidity index of ≥3. Log-binomial regression models were constructed to assess the effects of a patient's comorbidity index group on the risk of severe morbidity in high- and low-acuity hospitals. The models controlled for available patient and hospital factors. The regression used patient-level data with robust standard errors that were clustered at the level of the hospital. The Wald test was used to assess for the effect modification between comorbidity index group and hospital acuity.

Results: From 1203 hospitals, 1,656,659 delivering patients met the inclusion criteria. There were 58.7% low-risk, 39.0% intermediate-risk, and 2.3% high-risk patients in the overall sample, and the overall rate of severe maternal morbidity was 1.2%. Less than 3.7% of delivering patients in low-acuity hospitals had a high-risk condition. In comparison, >7.1% patients in high-acuity centers had a high-risk condition. In the adjusted analysis, intermediate-risk patients had a slightly increased risk of morbidity in both low-acuity and high-acuity centers compared with low-risk patients (adjusted risk ratios, 1.53 [95% confidence interval, 1.33-1.77] vs 1.57 [95% confidence interval, 1.49-1.65]). However, there was a notable difference in the adjusted risk ratios for severe maternal morbidity in the high-risk population: the adjusted risk ratio was 9.55 (95% confidence interval, 6.83-13.35) in low-acuity hospitals compared with 6.50 (95% confidence interval, 5.94-7.09) in high-acuity hospitals.

Conclusion: High-risk patients have a higher risk of severe maternal morbidity at low-acuity hospitals compared with high-acuity centers. These findings support the concept of regionalization of maternity care to improve outcomes for high-risk patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajog.2018.04.015DOI Listing
July 2018

The Future of Cesarean Delivery Rates in the United States.

Clin Obstet Gynecol 2017 12;60(4):829-839

Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts.

The US cesarean delivery rate remains 30%-32%. Increases in maternal age, obesity, and diabetes put upward pressure on this rate. Alternatives to cesarean delivery, vaginal birth after cesarean (VBAC), and operative vaginal delivery, are underutilized and there are substantial challenges to their resurgence. Practice guidelines offer promise, but demonstrate only minor reductions in cesarean delivery. We estimate that the overall rate in the US will remain 27%-30% for the immediate future. As more states move to recognize the independent practice of midwifery and more payers seek lower cost options for childbirth, we anticipate the overall rate will drop to 20% or 25%, but not for another 15 years or more.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/GRF.0000000000000325DOI Listing
December 2017

Preconception Counseling for Women With Cardiac Disease.

Curr Treat Options Cardiovasc Med 2017 Sep;19(9):67

Department of OBGYN, FND4, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.

Opinion Statement: All providers who care for reproductive-aged women with cardiac disease should assess these patients' desires and plans for pregnancy at every encounter. For those considering pregnancy, preconception counseling, often performed by a maternal-fetal medicine specialist, can help patients understand the potential implications of pregnancy on their health and estimate the risks of an adverse cardiac event prior to conceiving. There are cardiac conditions, such as pulmonary hypertension and aortic stenosis, in which pregnancy may be contraindicated given the high morbidity and mortality; there are tools available to help quantify a patient's risk. Furthermore, some cardiac lesions may be inherited, which may warrant parental testing or a discussion of strategies to reduce the risk of an affected child, such as the use of assisted reproductive technologies. Preconception counseling is also important to identify other maternal risk factors, such as obesity, hypertension, and tobacco use, which are associated with adverse pregnancy outcomes and develop a strategy to mitigate their potential risks, ideally before pregnancy. For women on medications for their heart disease or other comorbidities, a thorough review of these medications can potentially avoid an exposure to a teratogen during conception and pregnancy. Once pregnant, a patient's obstetrical provider and cardiologist should work together to outline a plan to monitor a patient's cardiac status as the normal physiologic changes of pregnancy, such as increased blood volume and cardiac output, may challenge a patient's functional status and increase the risk for an adverse outcome. Labor and delivery planning are essential to ensure patients with cardiac disease deliver at the appropriate hospital, equipped with the staff and resources to care for women with complex conditions. In summary, preconception counseling aims to stratify a patient's risk in pregnancy, inform patients of possible complications, and discuss strategies to best ensure a healthy mother and baby during pregnancy, labor, and delivery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11936-017-0565-zDOI Listing
September 2017

Hospital-Level Variation in Postpartum Readmissions.

JAMA 2017 05;317(20):2128-2129

Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jama.2017.2830DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5815041PMC
May 2017

A multi-state analysis of postpartum readmissions in the United States.

Am J Obstet Gynecol 2016 Jul;215(1):113.e1-113.e10

Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA.

Background: Readmission rates are used as a quality metric in medical and surgical specialties; however, little is known about obstetrics readmissions.

Objective: Our goals for this study were to describe the trends in postpartum readmissions over time; to characterize the common indications and associated diagnoses for readmissions; and to determine maternal, delivery, and hospital characteristics that may be associated with readmission.

Study Design: Postpartum readmissions occurring within the first 6 weeks after delivery in California, Florida, and New York were identified between 2004 and 2011 in State Inpatient Databases. Of the 5,949,739 eligible deliveries identified, 114,748 women were readmitted over the 8-year period. We calculated the rates of readmissions and their indications by state and over time. The characteristics of the readmission stay, including day readmitted, length of readmission, and charge for readmission, were compared among the diagnoses. Odds ratios were calculated using a multivariate logistic regression to determine the predictors of readmission.

Results: The readmission rate increased from 1.72% in 2004 to 2.16% in 2011. Readmitted patients were more likely to be publicly insured (54.3% vs 42.0%, P < .001), to be black (18.7% vs 13.5%, P < .001), to have comorbidities such as hypertension (15.3% vs 2.4%, P < 0.001) and diabetes (13.1% vs 6.8%, P < .001), and to have had a cesarean delivery (37.2% vs 32.9%, P < .001). The most common indications for readmission were infection (15.5%), hypertension (9.3%), and psychiatric illness (7.7%). Patients were readmitted, on average, 7 days after discharge, but readmission day varied by diagnosis: day 3 for hypertension, day 5 for infection, and day 9 for psychiatric disease. Maternal comorbidities were the strongest predictors of postpartum readmissions: psychiatric disease, substance use, seizure disorder, hypertension, and tobacco use.

Conclusion: Postpartum readmission rates have risen over the last 8 years. Understanding the risk factors, etiologies, and cause-specific timing for postpartum readmissions may aid in the development of new quality metrics in obstetrics and targeted strategies to curb the rising rate of postpartum readmissions in the United States.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajog.2016.01.174DOI Listing
July 2016

Effect of race/ethnicity on risk of complete and partial molar pregnancy after adjustment for age.

Gynecol Oncol 2016 10 30;143(1):73-76. Epub 2016 Jul 30.

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, USA; Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA; New England Trophoblastic Disease Center, Donald P. Goldstein, MD, Trophoblastic Tumor Registry, Boston, USA; Gynecologic Oncology Program, Susan F. Smith Center for Women's Cancers, Dana Farber Cancer Institute/Harvard Cancer Center, Boston, USA. Electronic address:

Objective: To quantify the effect of race/ethnicity on risk of complete and partial molar pregnancy.

Methods: We conducted a cross-sectional study including women who were followed for complete or partial mole and those who had a live singleton birth in a teaching hospital in the northeastern United States between 2000 and 2013. We calculated race/ethnicity-specific risk of complete and partial mole per 10,000 live births, and used logistic regression to estimate crude and age-adjusted relative risks (RR) of complete and partial mole.

Results: We identified 140 cases of complete mole, 115 cases of partial mole, and 105,942 live births. The risk of complete mole was 13 cases per 10,000 live births (95% confidence interval [CI] 11-16) and that of partial mole was 11 cases per 10,000 live births (95% CI 9-13). After age-adjustment, Asians were more likely to develop complete mole (RR 2.3 95% CI 1.4-3.8, p<0.001) but less likely to develop partial mole (RR 0.2; 95% CI 0.04-0.7, p=0.02) than whites. Blacks were significantly less likely than whites to develop partial mole (RR 0.4; 95% CI 0.2-0.8, p=0.01) but only marginally less likely to develop complete mole (RR 0.6; 95% CI 0.3-1.0, p=0.07). Hispanics were less likely than whites to develop complete mole (RR 0.4; 95% CI 0.2-0.7, p=0.002) and partial mole (RR 0.4; 95% CI 0.2-0.9, p=0.02).

Conclusion: Race/ethnicity is a significant risk factor for both complete and partial molar pregnancy in the northeastern United States.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ygyno.2016.07.117DOI Listing
October 2016