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OBJECTIVE: This study aimed to identify characteristics of patients with frequent obstetric triage visits ("superusers") compared to those with fewer visits and to evaluate the association of frequent obstetric triage visits with preterm birth and cesarean delivery. STUDY DESIGN: This retrospective cohort included patients presenting to the obstetric triage unit at a tertiary care center from March through April 2014. Superusers were defined as individuals having four or more triage visits. Participant characteristics, including demographic, clinical, visit acuity, and health care characteristics of superusers and nonsuperusers, were summarized and compared. In the subset of patients where data were available regarding prenatal care, prenatal visit patterns were analyzed and compared between the two groups. The outcomes of preterm birth and cesarean were compared between groups using modified Poisson regression to control for confounding. RESULTS: Of the 656 patients evaluated in the obstetric triage unit during the study period, 648 patients met the inclusion criteria. Factors associated with frequent triage use included race/ethnicity, multiparity, insurance status, high-risk pregnancy, and a prior preterm birth. Superusers were more likely to present at an earlier gestational age and had a higher proportion of visits for hypertensive disease. Patient acuity scores were not different between the groups. In the subset of patients receiving prenatal care at the institution, prenatal visit patterns were similar. The risk of preterm birth (adjusted risk ratio [aRR]: 1.06; 95% confidence interval [CI]: 0.66-1.70) did not differ between groups; however, the risk of a cesarean delivery was increased in superusers (aRR: 1.39; 95% CI: 1.01-1.92) when compared to nonsuperusers. CONCLUSION: Superusers, compared to nonsuperusers, have distinct clinical and demographic characteristics and are more likely to be seen in the triage unit at earlier gestational ages. Superusers tended to have a higher proportion of visits for hypertensive disease and had an increased risk of cesarean delivery. KEY POINTS: · Patients with frequent triage visits did not have an increased risk of preterm birth.. · Patients with frequent triage visits were more likely to undergo cesarean delivery.. · Acuity scales were similar for patients with frequent visits compared to those with few visits..
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OBJECTIVE: To evaluate the performance of B-type natriuretic peptide as a diagnostic tool for heart failure in pregnant or postpartum women with singleton gestations. METHODS: We conducted a retrospective study of diagnostic accuracy. We identified pregnant and postpartum women with B-type natriuretic peptide and echocardiography performed at an obstetric teaching hospital from 2007 to 2018. Women with known cardiac disease or multiple gestation were excluded. A panel of two cardiovascular disease experts, blinded to B-type natriuretic peptide values, determined the diagnosis of heart failure by consensus. Their judgement was based on detailed clinical features and parameters at the time of presentation with suspected heart failure. Where consensus could not be reached, differences were adjudicated by a third expert. A receiver operating characteristic curve estimated the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of B-type natriuretic peptide at various thresholds. RESULTS: In total, 22 pregnant and 38 postpartum women were included in the cohort. Average age was 32±6.8 years. The most common clinical features at the time of presentation with suspected heart failure included preeclampsia (33/60, 55%), dyspnea (50/60, 83%), chest discomfort (34/60, 58%), and bilateral lower extremity edema (32/60, 53%). In total, 39 (65%) women had heart failure. The median B-type natriuretic peptide level was 326 pg/mL (interquartile range 200.5-390.5) in women with heart failure, as compared with 75.5 pg/mL (interquartile range 19-245) in women without heart failure (P<.01). The estimated optimal B-type natriuretic peptide cutoff was 111 (95% CI 78-291) pg/mL. Using this threshold, 45 (75%) women had an elevated B-type natriuretic peptide, which yielded a 95% sensitivity (95% CI 83-99), 62% specificity (95% CI 38-82), a positive likelihood ratio of 2.5 (95% CI 1.4-4.3), and a negative likelihood ratio of 0.1 (95% CI 0.0-0.3) for heart failure. CONCLUSIONS: B-type natriuretic peptide is a useful clinical tool to evaluate pregnant and postpartum women with suspected heart failure.