Timing of Maternal Discharge after Cesarean Delivery and Risk of Maternal Readmission.

OBJECTIVE: Despite legislation and hospital policies (present in some institutions) mandating a minimum length of stay in an effort to decrease the frequency of hospital readmissions, the effectiveness of this approach remains uncertain.We hypothesized that following cesarean delivery (CD), the rates of maternal readmission or unscheduled health care visits are lower in patients discharged on postoperative day (POD) 3 or ≥4 as compared with those discharged earlier on POD 2. METHODS: This is a secondary analysis of a multicenter randomized trial comparing adjunctive azithromycin for unscheduled CD to prevent infection. Groups were compared based on the duration of hospitalization measured in days from delivery (POD 0) to day of discharge and categorized as POD 2, 3, and ≥4. The primary outcome was the composite of any maternal postpartum readmission, unscheduled clinic, or emergency room (ER) visit, within 6 weeks of delivery. Secondary outcomes included components of the primary outcome and neonatal readmissions. We excluded women with hypertensive disorders of pregnancy and infections diagnosed prior to POD 2. RESULTS: A total of 1,391 patients were included. The rate of the primary outcome of any readmission increased with POD at discharge: 5.9% for POD 2, 9.4% for POD 3, and 10.9% for POD ≥4 group (trend for p = 0.03). The primary outcome increased with later discharge (POD ≥4 when compared with POD 2). Among components of the composite, ER and unscheduled clinic visits, but not maternal readmissions, increased with the timing of discharge for patients discharged on POD ≥4 when compared with POD 2. Using logistic regression, discharge on POD 3 and on POD ≥4 was significantly associated with the composite (adjusted odds ratios [aOR] 2.6, 95% confidence interval [CI] [1.3-5.3]; aOR 2.9, 95% CI [1.3-6.4], respectively) compared with POD 2. CONCLUSION: The risk of maternal readmission composite following uncomplicated but unscheduled CD was not lower in patients discharged home on POD 3 or ≥4 compared with patients discharged earlier (POD 2). KEY POINTS: · Risk of maternal readmission is higher in patients discharged on POD 3 or 4 compared with POD 2.. · No significant differences by the timing of discharge were observed for any neonatal readmissions.. · Timing of discharge should include an individualized approach with the option of discharge by POD 2..

Prospective, randomized, double-blind, placebo-controlled evaluation of the Pharmacokinetics, Safety and Efficacy of Recombinant Antithrombin Versus Placebo in Preterm Preeclampsia.

BACKGROUND: Despite expectant management, preeclampsia remote from term usually results in preterm delivery. Antithrombin, which displays antiinflammatory and anticoagulant properties, may have a therapeutic role in treating preterm preeclampsia, a disorder characterized by endothelial dysfunction, inflammation, and activation of the coagulation system. OBJECTIVE: This randomized, placebo-controlled clinical trial aimed to evaluate whether intravenous recombinant human antithrombin could prolong gestation and therefore improve maternal and fetal outcomes. STUDY DESIGN: We performed a double-blind, placebo-controlled trial at 23 hospitals. Women were eligible if they had a singleton pregnancy, early-onset or superimposed preeclampsia at 23 0/7 to 30 0/7 weeks' gestation, and planned expectant management. In addition to standard therapy, patients were randomized to receive either recombinant human antithrombin 250 mg loading dose followed by a continuous infusion of 2000 mg per 24 hours or an identical saline infusion until delivery. The primary outcome was days gained from randomization until delivery. The secondary outcome was composite neonatal morbidity score. A total of 120 women were randomized. RESULTS: There was no difference in median gestational age at enrollment (27.3 weeks' gestation for the recombinant human antithrombin group [range, 23.1-30.0] and 27.6 weeks' gestation for the placebo group [range, 23.0-30.0]; P=.67). There were no differences in median increase in days gained (5.0 in the recombinant human antithrombin group [range, 0-75] and 6.0 for the placebo group [range, 0-85]; P=.95). There were no differences between groups in composite neonatal morbidity scores or in maternal complications. No safety issues related to recombinant human antithrombin were noted in this study, despite the achievement of supraphysiological antithrombin concentrations. CONCLUSION: The administration of recombinant human antithrombin in preterm preeclampsia neither prolonged pregnancy nor improved neonatal or maternal outcomes.

Maternal Race/Ethnicity, Hypertension, and Risk for Stroke During Delivery Admission.

Background Racial disparities contribute to maternal morbidity in the United States. Hypertension is associated with poor maternal outcomes, including stroke. Disparities in hypertension might contribute to maternal strokes. Methods and Results Using billing data from the Healthcare Cost and Utilization Project's National Inpatient Sample, we analyzed the effect of race/ethnicity on stroke during delivery admission in women aged 18 to 54 years delivering in US hospitals from January 1, 1998, through December 31, 2014. We categorized hypertension as normotensive, chronic hypertension, or pregnancy-induced hypertension. Adjusted risk ratios (aRRs) and 95% CIs were calculated using log-linear Poisson regression models, testing for interactions between race/ethnicity and hypertensive status. A total of 65 286 425 women were admitted for delivery during the study period, of whom 7764 were diagnosed with a stroke (11.9 per 100 000 deliveries). Hypertension modified the effect of race/ethnicity (P<0.0001 for interaction). Among women with pregnancy-induced hypertension, black and Hispanic women had higher stroke risk compared with non-Hispanic whites (blacks: aRR, 2.07; 95% CI, 1.86-2.30; Hispanics: aRR, 2.19; 95% CI, 1.98-2.43). Among women with chronic hypertension, all minority women had higher stroke risk (blacks: aRR, 1.71; 95% CI, 1.30-2.26; Hispanics: aRR, 1.75; 95% CI, 2.32-5.63; Asian/Pacific Islanders: aRR, 3.62; 95% CI, 2.32-5.63). Among normotensive women, only blacks had increased stroke risk (aRR, 1.17; 95% CI, 1.07-1.28). Conclusions Pregnant US women from minority groups had higher stroke risk during delivery admissions, compared with non-Hispanic whites. The effect of race/ethnicity was larger in women with chronic hypertension or pregnancy-induced hypertension. Targeting blood pressure management in pregnancy may help reduce maternal stroke risk in minority populations.

Use of Antihypertensive Medications and Uterotonics During Delivery Hospitalizations in Women With Asthma.

OBJECTIVE: To estimate whether the diagnosis of asthma is associated with the use of specific uterotonic and antihypertensive medications during delivery hospitalizations. METHODS: We used Perspective, an administrative database, to determine whether women hospitalized for delivery complicated by postpartum hemorrhage or preeclampsia received uterotonics and antihypertensive medications differentially based on the absence or presence of asthma from 2006 to 2015. Given that carboprost and intravenous (IV) labetalol may be associated with asthma exacerbation, adjusted models for receipt of these medications were created with adjusted risk ratios with 95% CIs as measures of effect. Risk for status asthmaticus based on receipt of carboprost and IV labetalol was analyzed. RESULTS: Over the study period, a total of 5,691,178 women were analyzed, of whom 239,915 (4.2%) had preeclampsia and 139,841 postpartum hemorrhage (2.5%). Carboprost was used less frequently in patients with asthma compared with patients with no asthma (11.4% vs 18.0%) in comparison with IV labetalol, which was used more commonly when a diagnosis of asthma was present (18.5% vs 16.7%). In unadjusted analysis, the presence of asthma was associated with a 37% decrease in likelihood of carboprost use and an 11% increase in likelihood of labetalol use. In adjusted analysis, the presence of asthma was associated with a 32% decrease in likelihood of carboprost use (adjusted risk ratio 0.68, 95% CI 0.62-0.74) compared with a 7% decrease in labetalol use (adjusted risk ratio 0.93, 95% CI 0.90-0.97). Risk for status asthmaticus was significantly increased with use of IV labetalol compared with other antihypertensive medications (6.5 vs 1.7/1,000 delivery hospitalizations, P<.01). CONCLUSION: There may be an opportunity to reduce use of ß-blockers and carboprost among patients with asthma. Given their association with status asthmaticus, these drugs should be used cautiously in women with asthma.

Use of Antihypertensive Medications During Delivery Hospitalizations Complicated by Preeclampsia.

OBJECTIVE: To evaluate temporal trends in use of antihypertensive medications during delivery hospitalizations complicated by preeclampsia and risk of maternal stroke over the same time period. METHODS: The Perspective database was used to perform a retrospective cohort study evaluating antihypertensive drugs dispensed during delivery hospitalizations complicated by preeclampsia from 2006 to the first quarter of 2015. Medications evaluated included nifedipine, hydralazine, and oral and intravenous labetalol. Adjusted models for receipt of antihypertensive agents accounting for demographic and hospital factors were created. Hospital-level rates of antihypertensive administration for women with severe preeclampsia were analyzed. Risk of stroke during delivery hospitalization was evaluated. RESULTS: A total of 239,454 patients with preeclampsia were included in the analysis including 126,595 women with mild, 31,628 with superimposed, and 81,231 with severe preeclampsia. Overall, 105,409 women received a hypertensive agent. From 2006 to 2014, for all patients with preeclampsia, receipt of oral labetalol increased from 20.3% to 31.4%, intravenous labetalol from 13.3% to 21.4%, hydralazine from 12.8% to 16.9%, nifedipine from 15.0% to 18.2%, and more than one medication from 16.5% to 25.8%. The proportion of patients with preeclampsia receiving any antihypertensive medication rose from 37.8% in 2006 to 49.4% in 2015. In adjusted models, temporal trends retained significance. Rates of antihypertensive administration for severe preeclampsia varied significantly by hospital. For severe preeclampsia, the risk for stroke decreased from 13.5 per 10,000 deliveries in 2006-2008 (n=27) to 9.7 in 2009-2011 (n=25) to 6.0 in 2012-2014 (n=20) (P=.02). CONCLUSION: Use of multiple antihypertensive agents to treat preeclamptic women increased over the study period for women with mild, superimposed, and severe preeclampsia. There was substantial hospital variation in use of antihypertensive agents. This trend was associated with decreased risk of maternal stroke.

Pulmonary arterial hypertension in pregnancy.

Pulmonary hypertension is a medical condition characterized by elevated pulmonary arterial pressure and secondary right heart failure. Pulmonary arterial hypertension is a subset of pulmonary hypertension, which is characterized by an underlying disorder of the pulmonary arterial vasculature. Pulmonary hypertension can also occur secondarily to structural cardiac disease, autoimmune disorders, and toxic exposures. Although pregnancies affected by pulmonary hypertension and pulmonary arterial hypertension are rare, the pathophysiology exacerbated by pregnancy confers both high maternal and fetal mortality and morbidity. In light of new treatment modalities and the use of a multidisciplinary approach to care, maternal outcomes may be improving.

Prediction and prevention of ischemic placental disease.

Preeclampsia, intrauterine growth restriction (IUGR), and placental abruption are obstetrical conditions that constitute the syndrome of ischemic placental disease or IPD, the leading cause of indicated preterm birth and an important cause of neonatal morbidity and mortality. While the phenotypic manifestations vary significantly for preeclampsia, IUGR, and abruption, these conditions may share a common underlying etiology as evidenced by: (1) shared clinical risk factors, (2) increased recurrence risk across pregnancies as well as increased co-occurrence of IPD conditions within a pregnancy, and (3) findings that suggest the underlying pathophysiologic processes may be similar. IPD is of major clinical importance and accounts for a large proportion of indicated preterm delivery ranging from the periviable to late preterm period. Successful prevention of IPD and resultant preterm delivery could substantially improve neonatal and maternal outcomes. This article will review the following topics: (1) The complicated research literature on aspirin and the prevention of preeclampsia and IUGR. (2) Research evidence on other medical interventions to prevent IPD. (3) New clinical interventions currently under investigations, including statins. (4) Current clinical recommendations for prevention of ischemic placental disease.