Postpartum readmission for hypertension and pre-eclampsia: development and validation of a predictive model

OBJECTIVE

To develop a model for predicting postpartum readmission for hypertension and pre-eclampsia at delivery discharge and assess external validation or model transportability across clinical sites.

DESIGN

Prediction model using data available in the electronic health record from two clinical sites.

SETTING

Two tertiary care health systems from the Southern (2014-2015) and Northeastern USA (2017-2019).

POPULATION

A total of 28 201 postpartum individuals: 10 100 in the South and 18 101 in the Northeast.

METHODS

An internal-external cross validation (IECV) approach was used to assess external validation or model transportability across the two sites. In IECV, data from each health system were first used to develop and internally validate a prediction model; each model was then externally validated using the other health system. Models were fit using penalised logistic regression, and accuracy was estimated using discrimination (concordance index), calibration curves and decision curves. Internal validation was performed using bootstrapping with bias-corrected performance measures. Decision curve analysis was used to display potential cut points where the model provided net benefit for clinical decision-making.

MAIN OUTCOME MEASURES

The outcome was postpartum readmission for either hypertension or pre-eclampsia <6 weeks after delivery.

RESULTS

The postpartum readmission rate for hypertension and pre-eclampsia overall was 0.9% (0.3% and 1.2% by site, respectively). The final model included six variables: age, parity, maximum postpartum diastolic blood pressure, birthweight, pre-eclampsia before discharge and delivery mode (and interaction between pre-eclampsia × delivery mode). Discrimination was adequate at both health systems on internal validation (c-statistic South: 0.88; 95% confidence interval [CI] 0.87-0.89; Northeast: 0.74; 95% CI 0.74-0.74). In IECV, discrimination was inconsistent across sites, with improved discrimination for the Northeastern model on the Southern cohort (c-statistic 0.61 and 0.86, respectively), but calibration was not adequate. Next, model updating was performed using the combined dataset to develop a new model. This final model had adequate discrimination (c-statistic: 0.80, 95% CI 0.80-0.80), moderate calibration (intercept -0.153, slope 0.960, Emax 0.042) and provided superior net benefit at clinical decision-making thresholds between 1% and 7% for interventions preventing readmission. An online calculator is provided here.

CONCLUSIONS

Postpartum readmission for hypertension and pre-eclampsia may be accurately predicted but further model validation is needed. Model updating using data from multiple sites will be needed before use across clinical settings.

Anticipated Impact of Dobbs v Jackson Women's Health Organization on Training of Residents in Obstetrics and Gynecology: A Qualitative Analysis

Background

On June 24, 2022, the Supreme Court of the United States in the case of Dobbs v Jackson Women's Health Organization ended constitutional protection for abortion, thus severely restricting access to reproductive health care for millions of individuals. Concerns have arisen about the potential impact on medical students, residents, and fellows training in restricted areas and the effect on gynecologic training and the future provision of competent comprehensive women's health care in the United States.

Objective

To qualitatively explore the anticipated impacts of the Dobbs ruling on training in obstetrics and gynecology (OB/GYN).

Methods

A participatory action research approach employing methods of qualitative analysis was used. Trainees and leaders in national OB/GYN professional and academic organizations with missions related to clinical care and training of medical students, residents, and fellows in OB/GYN participated. Two focus groups were held via Zoom in July 2022. Using an iterative process, transcripts underwent coding by 2 independent researchers to identify categories and common themes. Themes were organized into categories and subcategories. An additional reviewer resolved discrepancies.

Results

Twenty-six OB/GYN leaders/stakeholders representing 14 OB/GYN societies along with 4 trainees participated. Eight thematic categories were identified: competency, provision of reproductive health care, residency selection, inequity in training, alternative training, law-based vs evidence-based medicine, morality and ethics, and uncertainty about next steps.

Conclusions

This qualitative study of leaders and learners in OB/GYN identified 8 themes of potential impacts of the Dobbs ruling on current and future training in OB/GYN.

Postoperative spinal cord infarction on a gravid woman with suspected IV drug use: a case report

BACKGROUND

Back pain is common in the gravid population and spinal cord infarction (SCI) or chronic osteomyelitis are exceptionally rare underlying causes of back pain in this population. No case report to date has described this unexpected adverse event in a gravid woman with suspected history of IV drug use (IVDU). This diagnosis could potentially become more common with increasing rates of IVDU, and increased education could result in sooner recognition.

CASE

A 38 year old G9P0171 at 24 weeks gestation with a complex past medical history, and a suspected history of IVDU, presented repeatedly with back pain. Following cesarean delivery at 36w2d, she developed signs and symptoms of an anterior spinal artery syndrome (ASAS) and had evidence of chronic osteomyelitis at T9-T10 on imaging. This required emergent decompressive laminectomy and ultimately resulted in paraplegia.

CONCLUSION

This case highlights the difficulties in recognizing all SCI risk factors pre-operatively and the importance of investigating back pain in pregnant patients with a suspected history of IVDU. We believe this patient's chronic infection put her at an increased risk for SCI that was possibly compounded by the anatomical changes from its chronicity, possibly occurring in combination with several other precipitating causes of hypoperfusion. We hope this case report highlights the modern necessity to include a history, or suspected history, of IVDU as a red flag to initiate imaging in pregnant patients with acute, persistent, or unresolved back pain.

The elusive diagnosis and emergent management of a late-presenting ruptured interstitial pregnancy: a case report

Background

Interstitial pregnancies are rare and often difficult to diagnose given their proximal position to the uterine cavity, however most are identified by 12 weeks gestation. Delayed or missed diagnosis contributes to heightened incidence of poor outcomes including hemorrhage and death.

Case presentation

A 35-year-old woman at 15 weeks gestation with confirmed intrauterine pregnancy on first trimester ultrasound and prior negative MRI presented in hemorrhagic shock and was found to have a ruptured interstitial pregnancy. Exploratory laparotomy revealed the fetus to be in the abdomen as well as a large cornual defect and abnormal placentation that resulted in supracervical hysterectomy.

Conclusions

Interstitial pregnancy should be considered in a patient presenting with symptoms consistent with ectopic rupture, especially in the setting of equivocal or suboptimal prior imaging. Earlier diagnosis may allow for fertility-sparing intervention and decreased risk of morbidity and mortality.

Risk factors for postpartum readmission for preeclampsia or hypertension before delivery discharge among low-risk women: a case-control study

BACKGROUND

Postpartum hypertension or preeclampsia is one of the most frequent reasons for readmission after delivery discharge, and risk factors for readmission remain poorly characterized.

OBJECTIVE

This study aimed to determine risk factors of postpartum readmission for hypertension or preeclampsia among low-risk women before delivery discharge.

STUDY DESIGN

We conducted a nested case-control study from 2012 to 2015 at a tertiary care medical center. Cases were identified using diagnostic codes for postpartum transient hypertension, mild preeclampsia, severe preeclampsia, eclampsia, superimposed preeclampsia, and unspecified hypertension and readmission within 6 weeks of delivery. Controls not readmitted for hypertension or preeclampsia were time matched within 4 weeks of the delivery date to each case. We fit multivariable logistic regression models to identify independent risk factors for postpartum readmission for hypertension or preeclampsia and then calculated a receiver operating characteristic curve of the final model to assess model discrimination.

RESULTS

Within the source cohort resulting in 58 cases and 232 matched controls, the rate of postpartum readmission for preeclampsia or hypertension was 0.4% (n=58 of 14,503). The median time to readmission was 6 days (range, 2-15 days), and 40% of cases had an outpatient postpartum visit before readmission. In multivariable analysis, non-Hispanic black race (adjusted odds ratio, 2.14; 95% confidence interval, 0.99-4.59), gestational hypertension (adjusted odds ratio, 2.70; 95% confidence interval, 1.12-6.54), preeclampsia during delivery admission (adjusted odds ratio, 3.12; 95% confidence interval, 1.29-7.50), and maximum postpartum systolic blood pressure during delivery admission (adjusted odds ratio, 1.05; 95% confidence interval, 1.03-1.08) were risk factors for readmission. This model had a good discriminative ability to predict women who would require readmission for preeclampsia or hypertension (area under the curve, 0.83; 95% confidence interval, 0.74-0.89). Using these 4 factors to illustrate this model, the predicted risk of readmission ranged from <1% in the lowest risk scenario (eg, postpartum systolic blood pressure of 120 mm Hg + no hypertensive disorders of pregnancy + white race) to 26% in the highest risk scenario (eg, postpartum systolic blood pressure of 160 mm Hg + preeclampsia + black race).

CONCLUSION

Risk factors of postpartum readmission for hypertension or preeclampsia can be identified at the time of delivery discharge among low-risk women, regardless of an antenatal hypertensive disorder. A next step could be using these risk factors to develop a predictive model to guide postpartum care.

The Gestational Diabetes Management System (GooDMomS): development, feasibility and lessons learned from a patient-informed, web-based pregnancy and postpartum lifestyle intervention

BACKGROUND

Gestational diabetes mellitus (GDM) contributes to the epidemic of diabetes and obesity in mothers and their offspring. The primary objective of this pilot study was to: 1) refine the GDM Management System (GooDMomS), a web-based pregnancy and postpartum behavioral intervention and 2) assess the feasibility of the intervention.

METHODS

In phase 1, ten semi-structured interviews were conducted with women experiencing current or recent GDM mellitus GDM to garner pilot data on the web based intervention interface, content, and to solicit recommendations from women about refinements to enhance the GooDMomS intervention site. Interviews were audiotaped, transcribed and independently reviewed to identify major themes with Atlas.ti v7.0. In phase 2, a single-arm feasibility study was conducted and 23 participants were enrolled in the GooDMomS program. Participants received web lessons, self-tracking of weight and glucose, automated feedback and access to a message board for peer support. The primary outcome was feasibility, including recruitment and retention and acceptability. Secondary outcomes included the proportion of women whose gestational weight gain (GWG) was within the Institute of Medicine (IOM) guidelines and who were able to return to their pre-pregnancy weight after delivery.

RESULTS

Comments from semi-structured interviews focused on: 1) usability of the on-line self-monitoring diary and tracking system, 2) access to a safe, reliable social network for peer support and 3) ability of prenatal clinicians to access the on-line diary for clinical management. Overall, 21 (91 %) completed the pregnancy phase. 15/21 (71 %) of participants were within the Institute of Medicine (IOM) guidelines for GWG. Sixteen (70 %) completed the postpartum phase. 7/16 (43 %) and 9/16 (56 %) of participants returned to their pre-pregnancy weight at 6 and 30 weeks postpartum, respectively.

CONCLUSIONS

This study documents the feasibility of the GooDMomS program. The results can have implications for web technology in perinatal care and inform the current care paradigm for women with GDM. Findings are supportive of further research with recruitment of a larger sample of participants and comparison of the outcomes with the intervention and standard care.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov on May 15, 2012 under protocol no. NCT01600534 .

Internet Use and Access Among Pregnant Women via Computer and Mobile Phone: Implications for Delivery of Perinatal Care

Background

The use of Internet-based behavioral programs may be an efficient, flexible method to enhance prenatal care and improve pregnancy outcomes. There are few data about access to, and use of, the Internet via computers and mobile phones among pregnant women.

Objective

We describe pregnant women’s access to, and use of, computers, mobile phones, and computer technologies (eg, Internet, blogs, chat rooms) in a southern United States population. We describe the willingness of pregnant women to participate in Internet-supported weight-loss interventions delivered via computers or mobile phones.

Methods

We conducted a cross-sectional survey among 100 pregnant women at a tertiary referral center ultrasound clinic in the southeast United States. Data were analyzed using Stata version 10 (StataCorp) and R (R Core Team 2013). Means and frequency procedures were used to describe demographic characteristics, access to computers and mobile phones, and use of specific Internet modalities. Chi-square testing was used to determine whether there were differences in technology access and Internet modality use according to age, race/ethnicity, income, or children in the home. The Fisher’s exact test was used to describe preferences to participate in Internet-based postpartum weight-loss interventions via computer versus mobile phone. Logistic regression was used to determine demographic characteristics associated with these preferences.

Results

The study sample was 61.0% white, 26.0% black, 6.0% Hispanic, and 7.0% Asian with a mean age of 31.0 (SD 5.1). Most participants had access to a computer (89/100, 89.0%) or mobile phone (88/100, 88.0%) for at least 8 hours per week. Access remained high (>74%) across age groups, racial/ethnic groups, income levels, and number of children in the home. Internet/Web (94/100, 94.0%), email (90/100, 90.0%), and Facebook (50/100, 50.0%) were the most commonly used Internet technologies. Women aged less than 30 years were more likely to report use of Twitter and chat rooms compared to women 30 years of age or older. Of the participants, 82.0% (82/100) were fairly willing or very willing to participate in postpartum lifestyle intervention. Of the participants, 83.0% (83/100) were fairly willing or very willing to participate in an Internet intervention delivered via computer, while only 49.0% (49/100) were fairly willing or very willing to do so via mobile phone technology. Older women and women with children tended to be less likely to desire a mobile phone-based program.

Conclusions

There is broad access and use of computer and mobile phone technology among southern US pregnant women with varied demographic characteristics. Pregnant women are willing to participate in Internet-supported perinatal interventions. Our findings can inform the development of computer- and mobile phone-based approaches for the delivery of clinical and educational interventions.