Postpartum blood pressure control and the rate of readmission.

BACKGROUND: Postpartum hypertension is a major contributor to the rising maternal mortality rates in the United States, with nearly half of maternal deaths occurring after delivery. Previous studies have found evidence that the maximum blood pressure reading during labor and delivery admission can predict readmission; however, the optimal blood pressure to reduce the need for readmissions and additional medical treatment in the postpartum period is not known. OBJECTIVE: This study aimed to investigate the relationship between postpartum blood pressure control at discharge and readmission within the first 6 weeks after delivery. STUDY DESIGN: Data were obtained from Cosmos, an electronic health record-based, Health Insurance Portability and Accountability Act-defined limited dataset that includes more than 1.4 million birth encounters. All birthing parents with blood pressure data after delivery were included. Demographic information, medications, and readmissions were queried from the dataset. Patients were grouped into categories based on blood pressure readings in the 24 hours before discharge (≥160/110, ≥150/100, ≥140/90, ≥130/80, ≥120/80, and <120/80 mm Hg). The readmission rates across these groups were compared. Planned subanalyses included stratification by the use of antihypertensive medications and a sensitivity analysis using the highest blood pressure during admission. Covariates included maternal age, preexisting diabetes mellitus or lupus erythematosus, and body mass index. RESULTS: The analysis included 1,265,766 total birth encounters, 391,781 (30.9%) in the referent group (120/80 mm Hg), 392,592 (31.0%) in the group with <120/80 mm Hg, 249,414 (19.7%) in the group with ≥130/80 mm Hg, 16,125 (1.3%) in the group with ≥140/90 mm Hg, 50,659 (4.0%) in the group with ≥150/100 mm Hg, and 20,196 (1.6%) in the group with ≥160/110 mm Hg. In the first 6 weeks after delivery, readmission rates increased with higher blood pressure readings. More than 5% of postpartum patients with the highest blood pressure readings (≥160/110 mm Hg) were readmitted. These patients were almost 3 times more likely to be readmitted than patients whose highest blood pressure reading fell into the referent group (120/80 mm Hg) (odds ratio [OR], 2.90; 95% confidence interval, 2.69-3.12). Patients with blood pressures of >150/100 mm Hg (odds ratio, 2.72; 95% confidence interval, 2.58-2.87), >140/90 mm Hg (odds ratio, 2.03; 95% confidence interval, 1.95-2.11), and >130/80 mm Hg (odds ratio, 1.43; 95% confidence interval, 1.37-1.49) all had higher odds of readmission, whereas patients with a blood pressure of <120/80 mm Hg had a lower odds of readmission (odds ratio, 0.78; 95% confidence interval, 0.75-0.81). Patients who had higher blood pressures during admission but had improved control in the 24 hours before discharge had lower rates of readmission than those whose blood pressures remained elevated. In all blood pressure categories, patients who received an antihypertensive prescription had higher rates of readmission. CONCLUSION: In this large, national dataset, blood pressure control at discharge and readmission in the postpartum period were significantly correlated. Our data should inform postpartum hypertension treatment goals and the role of remote monitoring programs in improving maternal safety.

Assessment of adherence to aspirin for preeclampsia prophylaxis and reasons for nonadherence.

BACKGROUND: Preeclampsia is a hypertensive disease unique to pregnancy and has a significant impact on maternal and neonatal morbidity and mortality. Daily aspirin has been demonstrated to reduce the risk of preeclampsia. The American College of Obstetricians and Gynecologists recommends daily low-dose aspirin, ideally before 16 weeks' gestation, in at-risk patients for preeclampsia risk reduction. This study examined whether patients at-risk for preeclampsia by the American College of Obstetricians and Gynecologists criteria recalled aspirin recommendation and factors associated with treatment adherence. OBJECTIVE: This study examined whether patients at-risk for preeclampsia by the American College of Obstetricians and Gynecologists criteria recalled aspirin recommendation and factors associated with treatment adherence. STUDY DESIGN: This study used an anonymous written survey. Pregnant patients were asked to record self-reported risk factors and to recall recommendation to take aspirin for preeclampsia prophylaxis. Participants were then determined to be high-, moderate-, or low-risk on the basis of the American College of Obstetricians and Gynecologists guidelines. Self-reported adherence to recommendations and factors contributing to the patients' decisions to take or decline aspirin were assessed. Secondary outcomes included demographic characteristics of adherent patients and patients who did not recall aspirin recommendation. RESULTS: A total of 544 surveys were distributed and 500 were returned (91.9% response rate). Of the 104 high-risk pregnancies identified, aspirin was recommended in 60 (57.7%; 95% confidence interval, 0.48-0.67). Of the 269 patients with 2 or more moderate-risk factors, aspirin was recommended for 13 (4.8%; 95% confidence interval, 0.03-0.08). Among the participants who recalled aspirin recommendation, adherence was similar between high-risk (81.7%) and moderate-risk (76.9%) groups (P=.69). Patients with chronic hypertension, a history of preeclampsia or gestational hypertension in a previous pregnancy, and pregestational diabetes mellitus were most likely to report receiving aspirin recommendation (78.8%, 76.5%, 63.8%, and 53.3%, respectively). No high-risk factor was associated with a decreased likelihood of adherence. Nonadherent patients rarely discussed their decision with their medical provider (5.9%). In the 42.3% of high-risk participants who did not recall aspirin recommendation, autoimmune disease, multiple gestation, and kidney disease were the most prevalent risk factors (42.9%, 35.7%, and 25.0%, respectively). CONCLUSION: In the population studied, many at-risk patients, as defined by the American College of Obstetricians and Gynecologists criteria, did not recall recommendations to take aspirin for preeclampsia prophylaxis. This raises concerns for absent or ineffective counseling. Of the patients who recalled aspirin recommendation, most reported adherence, and a history of hypertensive disorders or preeclampsia, autoimmune disease, and pregestational diabetes mellitus were most often associated with adherence. There was no single factor most strongly associated with intentional nonadherence.

Evaluation of multidisciplinary shoulder dystocia simulation training on knowledge, performance, and documentation.

BACKGROUND: Research has shown the utility of simulations involving individuals, yet little data exist on whether communication and documentation are impacted by the integration of all team members into a scenario. In 2018, the obstetrics department at this tertiary hospital began a multidisciplinary team-training simulation for shoulder dystocia. An educational portion was included, teaching a new practice where the provider announces delivery events (head, shoulder, body) to be marked on the delivery record, a standardized approach was introduced, and a pre- and post-simulation test was administered. OBJECTIVE: In this study, we sought to evaluate the lasting impact of this team-based tool on the outcomes and documentation of shoulder dystocia cases, specifically the recording of the exact shoulder dystocia duration in seconds. Secondary outcomes included evaluation of the documentation of shoulder dystocia maneuvers and a pre- and post-simulation knowledge test. Included in this test were questions from the validated survey, the Safety Attitudes Questionnaire, a tool focused on evaluating team dynamics and communication. It was hypothesized that this simulation would improve communication as shown by sustained improvement in documentation, competence in shoulder dystocia care, and confidence among members of the team as shown by improved scores on the Safety Attitudes Questionnaire. STUDY DESIGN: This was a retrospective cohort study of shoulder dystocia cases from 2017 and 2019 at a safety-net tertiary care hospital, 1 full year before and after the implementation of a multidisciplinary shoulder dystocia simulation in 2018. Delivery outcomes were compared, documentation of delivery event times was recorded and analyzed, and the delivery note was evaluated using the American College of Obstetricians and Gynecologists guidelines for shoulder dystocia. The surveys from participants were assessed for postsimulation improvement. Categorical variables were analyzed using chi-square tests and continuous variables were compared using Student t tests. Because shoulder dystocia duration is a nonparametric variable, this was compared using a Kruskal-Wallis test. RESULTS: There were 28 cases in the 2017 cohort and 25 in the 2019 cohort. In the 2017 cohort, 25% of delivery documentation (7 of 25) included the exact shoulder dystocia duration, which increased to 96% (24 of 25) in the 2019 cohort (P<.001). There was no significant impact on the shoulder dystocia duration (P=.163). On average, 2.7 maneuvers were required in the 2017 cohort, which increased to 3.4 maneuvers used in the 2019 cohort, showing a significant increase in the use of shoulder dystocia maneuvers (P=.030). The posttests showed no impact on shoulder dystocia background knowledge (P=.142) or knowledge of risk factors (P=.171) but did show an increased understanding of the definition and performance of shoulder dystocia maneuvers (P=.008). The Safety Attitudes Questionnaire revealed that simulation participants would feel safe being treated by their colleagues with a score of 4.7/5. On the paired responses after the simulation, nurses reported feeling that their input was more highly valued (P=.045), and participants of all disciplines felt they received adequate feedback on their performances (P=.041). CONCLUSION: A multidisciplinary simulation on shoulder dystocia led to sustained improvement in documentation and shoulder dystocia maneuvers used, suggesting increased comfort with advanced maneuvers. Future studies should evaluate whether multidisciplinary simulations, mimicking the normal delivery team, may lead to other sustained improvements in maternal care.

The association of HBB-related significant hemoglobinopathies and low fetal fraction on noninvasive prenatal screening for fetal aneuploidy.

OBJECTIVES: HBB-related significant hemoglobinopathies have been anecdotally associated with low fetal fraction on noninvasive prenatal screening (NIPS). We sought to compare the difference in fetal fraction using NIPS in women with HBB-related significant hemoglobinopathies (HSH) and women with normal hemoglobin. STUDY DESIGN: This is a retrospective case-control study. Cases were women with a diagnosis of HSH using NIPS from a commercial laboratory. The comparison group was women with hemoglobin AA from a tertiary care center database. We tested for differences in median fetal fraction using quantile regression analysis, adjusting for maternal body weight and gestational age. RESULTS: This study includes 35 women with clinically significant HSH and a comparison group of 636 women with hemoglobin AA. Adjusting for gestational age and body weight, the median fetal fraction was 4.1 point lower in the HSH than in the comparison group (ß - 4.1; 95% -5.7 to -2.5, p < .05). The rate of no-calls due to low fetal fraction was significantly higher in the clinically significant HSH group than in the comparison group [HSH: n = 9/35, 25.7% versus comparison: n = 32/636, 5.0% (p < .001)]. CONCLUSION: Women with HSH were more likely to have a lower fetal fraction and ultimately a five-fold higher no-call rate. What's already known about this topic?Low fetal fraction is one of the most common causes of no-call result in noninvasive prenatal screeningHigh maternal weight, early gestational age and fetal aneuploidies are associated with low fetal fraction What does this study add?HBB-related significant hemoglobinopathies are associated with low fetal fractionReduction in fetal fraction due to HBB-related significant hemoglobinopathies may also result in higher no-call rate.