Assessment of Incidence and Factors Associated With Severe Maternal Morbidity After Delivery Discharge Among Women in the US.

Importance: Previous efforts to examine severe maternal morbidity (SMM) in the US have focused on delivery hospitalizations. Little is known about de novo SMM that occurs after delivery discharge. Objective: To investigate the incidence, timing, factors, and maternal characteristics associated with de novo SMM after delivery discharge among women in the US. Design, Setting, and Participants: In this retrospective cohort study, data from the IBM MarketScan Multi-State Medicaid database and the IBM MarketScan Commercial Claims and Encounters database were used to construct a sample of women aged 15 to 44 years who delivered between January 1, 2010, and September 30, 2014. Severe maternal morbidity was reported by the timing of diagnosis, and the associated maternal characteristics were examined. Women in the Medicaid and commercial insurance sample were classified into 3 distinct outcome groups: (1) those without any SMM during the delivery hospitalization and the postdelivery period (reference group), (2) those who exhibited at least 1 factor associated with SMM during the delivery hospitalization, and (3) those who exhibited any factor associated with de novo SMM after delivery discharge (defined as SMM that was first diagnosed in the inpatient setting during the 6 weeks [or 42 days] after discharge from the delivery hospitalization, conditional on no factor associated with SMM being identified during delivery). Data were analyzed from February to July 2020. Exposures: Timing of SMM diagnosis. Main Outcomes and Measures: Women with SMM were identified using diagnosis and procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification for the 21 factors associated with SMM that were developed by the Centers for Disease Control and Prevention. Results: A total of 2 667 325 women in the US with delivery hospitalizations between 2010 and 2014 were identified; of those, 809 377 women (30.3%) had Medicaid insurance (30.3%; mean [SD] age, 25.6 [5.5] years; 51.1% White), and 1 857 948 women (69.7%; mean [SD] age, 30.6 [5.4] years; 36.4% from the southern region of the US) had commercial insurance. Among those with Medicaid insurance, 17 584 women (2.2%) experienced SMM during the delivery hospitalization, and 3265 women (0.4%) experienced de novo SMM after delivery discharge. Among those with commercial insurance, 32 079 women (1.7%) experienced SMM during the delivery hospitalization, and 5275 women (0.3%) experienced de novo SMM after hospital discharge. A total of 5275 SMM cases (14.1%) and 3265 SMM cases (15.7%) among women with commercial and Medicaid insurance, respectively, developed de novo within 6 weeks after hospital discharge; of those, 3993 cases (75.7%) in the commercial insurance cohort and 2399 cases (73.5%) in the Medicaid cohort were identified in the first 2 weeks after discharge. The most common factors associated with SMM varied based on the timing of diagnosis. In the Medicaid population, non-Hispanic Black women (adjusted odds ratio [aOR], 1.53; 95% CI, 1.48-1.58), Hispanic women (aOR, 1.46; 95% CI, 1.37-1.57), and women of other races or ethnicities (aOR, 1.40; 95% CI, 1.33-1.47) had higher rates of SMM during delivery hospitalization than non-Hispanic White women; however, only the disparity between Black and White women (aOR, 1.69; 95% CI, 1.57-1.81) persisted into the postdischarge period. Conclusions and Relevance: In this study, 15.7% of SMM cases in the Medicaid cohort and 14.1% of SMM cases in the commercial insurance cohort first occurred after the delivery hospitalization, with notable disparities in factors and maternal characteristics associated with the development of SMM. These findings suggest a need to expand the focus of SMM assessment to the postdelivery discharge period.

Postpartum hemorrhage outcomes and race.

BACKGROUND: How race is associated with adverse outcomes in the setting of postpartum hemorrhage is not well characterized. OBJECTIVE: The objective of this study was to assess how race is associated with adverse maternal outcomes in the setting of postpartum hemorrhage. STUDY DESIGN: This retrospective cohort study utilized the National (Nationwide) Inpatient Sample (NIS) from the Agency for Healthcare Research and Quality for the years 2012-2014. Women aged 15-54 years with a diagnosis of postpartum hemorrhage were included. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, Native American, other, and unknown. Overall risk for severe morbidity based on Centers for Disease Control and Prevention criteria was analyzed along with risk for specific outcomes such as disseminated intravascular coagulation, hysterectomy, transfusion, and maternal death. Risk for severe morbidity was stratified by comorbid risk and compared by race. Weights were applied to create population estimates. Log-linear regression models were created to assess risk for severe morbidity with risk ratios and associated 95% confidence intervals as measures of effect. RESULTS: A total of 360,370 women with postpartum hemorrhage from 2012 to 2014 were included in this analysis. Risk for severe morbidity was significantly higher among non-Hispanic black women (26.6%) than non-Hispanic white, Hispanic, or Asian or Pacific Islander women (20.7%, 22.5%, and 21.4%, respectively, P < .01). For non-Hispanic black compared with non-Hispanic white, Hispanic, and Asian or Pacific Islander women risk was higher for disseminated intravascular coagulation (8.4% vs 7.1%, 6.8%, and 6.8%, respectively, P < .01) and transfusion (19.4% vs 13.9%, 16.1%, and 15.8%, respectively, P < .01). Black women were also more likely than non-Hispanic white women to undergo hysterectomy (2.4% vs 1.9%, P < .01), although Asian or Pacific Islander women were at highest risk (2.9%). Adjusting for comorbidity, black women remained at higher risk for severe morbidity (P < .01). Risk for death for non-Hispanic black women was significantly higher than for nonblack women (121.8 per 100,000 deliveries, 95% confidence interval, 94.7-156.8 vs 24.1 per 100,000 deliveries, 95% confidence interval, 19.2-30.2, respectively, P < .01). CONCLUSION: Black women were at higher risk for severe morbidity and mortality associated with postpartum hemorrhage.

[Pulmonary echinococcosis, hepatic opisthorchiasis and generalized trichinelliasis combined with pregnancy]. / Ekhinokokk legkikh, opistorkhoz pecheni, generalizovannyi trikhinellez v sochetanii s beremennost'iu.

A case is reported of a spontaneous abortion (25 weeks of gestation) in a Nenets woman resulting in thrombohemorrhagic syndrome and profuse uterine bleeding. The abortion is attributed to drastic allergization by three parasites: Echinococcus granulosus, Opisthorchis felineus, Trichinella spiralis.