The Positive Predictive Value of Hospital Discharge Data for Identifying Severe Maternal Morbidity With and Without Blood Transfusion

BACKGROUND

Blood transfusion is 1 of the 21 indicators for severe maternal morbidity (SMM) as defined by the Centers for Disease Control and Prevention (CDC) using administrative data. The CDC SMM definition is being prepared to measure hospital quality of care; however, transfusion coding reliability has been questioned. The authors assessed the positive predictive value (PPV) of administrative data for identifying gold standard SMM using the CDC SMM definition, with and without the transfusion indicator.

METHODS

A retrospective cohort study of one hospital's childbirth admissions (2016-2019) was performed. Data were screened for CDC SMM, and subgroups were created for those with transfusion as the sole indicator for SMM (transfusion-only SMM) versus those with at least one other SMM indicator (other SMM). Medical chart review classified CDC SMM cases based on gold standard SMM criteria. Gold standard SMM was defined by validated indicators identified by internal hospital quality reviews and confirmed by expert consensus. The PPV was calculated for all CDC SMM cases and the subgroups.

RESULTS

Of 4,212 eligible people, 278 (6.6%) had CDC SMM. Chart review identified 110 gold standard SMM cases among screen-positive cases, yielding an overall PPV of the CDC SMM definition for gold standard SMM of 39.6%. CDC SMM cases identified solely by administrative coding for transfusion were half as likely to meet gold standard criteria, compared to cases identified by other SMM administrative codes (25.9% vs. 49.4%).

CONCLUSION

Blood transfusion, coded as an independent risk factor, had a poor PPV for gold standard SMM. Given efforts to use CDC SMM for quality comparisons, more research is needed to reliably identify cases of SMM without relying on blood transfusion codes.

Trends, Characteristics, and Maternal Morbidity Associated With Unhoused Status in Pregnancy

Importance

Unhoused status is a substantial problem in the US. Pregnancy characteristics and maternal outcomes of individuals experiencing homelessness are currently under active investigation to optimize health outcomes for this population.

Objective

To assess the trends, characteristics, and maternal outcomes associated with unhoused status in pregnancy.

Design, Setting, and Participants

This cross-sectional study analyzed data from the Healthcare Cost and Utilization Project National (Nationwide) Inpatient Sample. The study population included hospitalizations for vaginal and cesarean deliveries from January 1, 2016, to December 31, 2020. Unhoused status of these patients was identified from use of International Statistical Classification of Diseases, Tenth Revision, Clinical Modification code Z59.0. Statistical analysis was conducted from December 2022 to June 2023.

Main Outcomes and Measures

Primary outcomes were (1) temporal trends; (2) patient and pregnancy characteristics associated with unhoused status, which were assessed with a multivariable logistic regression model; (3) delivery outcomes, including severe maternal morbidity (SMM) and mortality at delivery, which used the Centers for Disease Control and Prevention definition for SMM indicators and were assessed with a propensity score-adjusted model; and (4) choice of long-acting reversible contraception method and surgical sterilization at delivery.

Results

A total of 18 076 440 hospital deliveries were included, of which 18 970 involved pregnant patients who were experiencing homelessness at the time of delivery, for a prevalence rate of 104.9 per 100 000 hospital deliveries. These patients had a median (IQR) age of 29 (25-33) years. The prevalence of unhoused patients increased by 72.1% over a 5-year period from 76.1 in 2016 to 131.0 in 2020 per 100 000 deliveries (P for trend < .001). This association remained independent in multivariable analysis. In addition, (1) substance use disorder (tobacco, illicit drugs, and alcohol use disorder), (2) mental health conditions (schizophrenia, bipolar, depressive, and anxiety disorders, including suicidal ideation and past suicide attempt), (3) infectious diseases (hepatitis, gonorrhea, syphilis, herpes, and COVID-19), (4) patient characteristics (Black and Native American race and ethnicity, younger and older age, low or unknown household income, obesity, pregestational hypertension, pregestational diabetes, and asthma), and (5) pregnancy characteristics (prior uterine scar, excess weight gain during pregnancy, and preeclampsia) were associated with unhoused status in pregnancy. Unhoused status was associated with extreme preterm delivery (<28-week gestation: 34.3 vs 10.8 per 1000 deliveries; adjusted odds ratio [AOR], 2.76 [95% CI, 2.55-2.99]); SMM at in-hospital delivery (any morbidity: 53.8 vs 17.7 per 1000 deliveries; AOR, 2.30 [95% CI, 2.15-2.45]); and in-hospital mortality (0.8 vs <0.1 per 1000 deliveries; AOR, 10.17 [95% CI, 6.10-16.94]), including case fatality risk after SMM (1.5% vs 0.3%; AOR, 4.46 [95% CI, 2.67-7.45]). Individual morbidity indicators associated with unhoused status included cardiac arrest (AOR, 12.43; 95% CI, 8.66-17.85), cardiac rhythm conversion (AOR, 6.62; 95% CI, 3.98-11.01), ventilation (AOR, 6.24; 95% CI, 5.03-7.74), and sepsis (AOR, 5.37; 95% CI, 4.53-6.36).

Conclusions and Relevance

Results of this national cross-sectional study suggest that unhoused status in pregnancy gradually increased in the US during the 5-year study period and that pregnant patients with unhoused status were a high-risk pregnancy group.

Infectious outcomes following immediate postplacental intrauterine device placement in the setting of chorioamnionitis: An exploratory, retrospective study

OBJECTIVE

To evaluate infectious outcomes following postplacental intrauterine device (PPIUD) placement in patients with suspected chorioamnionitis.

STUDY DESIGN

This retrospective cohort study identified individuals desiring PPIUD who subsequently developed suspected chorioamnionitis, treated with antibiotics. We followed 12-month infectious outcomes amongst two cohorts: (1) those who received PPIUD and (2) those with placement deferred.

RESULTS

Of 55 followed, 18 of 22 PPIUDs were placed before chorioamnionitis was suspected; 33 placements were deferred. Neither group experienced acute infectious complications. Notably, IUDs were more often deferred when chorioamnionitis was more clearly diagnosed (20/33, 60.6% vs 4/22, 18.2% p < 0.01). Overdiagnosis of chorioamnionitis prevented IUD uptake in 10 of 55 (18.2%) individuals in this sample.

CONCLUSIONS

PPIUD placement in individuals with early signs of chorioamnionitis may not result in severe morbidity, in a study limited by sample size. Larger, prospective studies are needed in well-defined cohorts.

IMPLICATIONS

Incidental, immediate postplacental IUD placement in individuals with treated, suspected chorioamnionitis was not associated with severe morbidity within 1-year postpartum. Larger-scale, prospective studies are needed to guide the management of incidentally-placed, postplacental IUDs in the setting of mild chorioamnionitis.

Trauma in pregnancy and severe adverse perinatal outcomes

BACKGROUND

Trauma, including accidental and violent trauma, is a rare but severe complication of pregnancy. The incidence of adverse perinatal outcomes in pregnancies affected by traumatic injury has not been well-studied.

OBJECTIVE

We sought to characterize the association between traumatic injury during pregnancy and severe adverse perinatal outcomes in a large population.

STUDY DESIGN

We performed a retrospective cohort study of California Birth Registry data from 2007 to 2011. ICD-9 diagnosis and procedure codes were used to categorize patients into trauma and non-trauma cohorts and to assess the prevalence of severe adverse fetal and neonatal outcomes. Chi-square tests were used to characterize maternal demographics and perform univariate analyses, and logistic regression was used to control for potential confounders.

RESULTS

Of 2,406,605 singleton nonanomalous pregnancies, 1262 (0.05%) experienced trauma prior to delivery. The rate of composite perinatal outcomes was higher in pregnancies with trauma compared to those without (3.1 versus 0.87%, p < .001). Trauma was associated with higher occurrences of preterm birth <37 weeks, preterm birth <32 weeks, very low birth weight and neonatal death. Fetal demise at any gestational age was more common among trauma patients (1.9 versus 0.53%, p < .001), though this difference was not statistically significant among term fetuses (0.28 versus 0.14%, p = .21). A difference in composite adverse perinatal outcomes was seen even after controlling for important maternal characteristics (aOR 3.2, 95% CI). Trauma patients with severe morbidity compared to those without had higher rates of preterm birth <37 weeks, preterm birth <32 weeks, and composite severe perinatal outcomes.

CONCLUSION

Trauma in pregnant women is associated with an increased risk of severe adverse perinatal outcomes, including fetal and neonatal demise. Prevalence of fetal demise is not different between trauma and non-trauma mothers when looking at term fetuses only, suggesting that the greatest risk of fetal demise in the setting of trauma occurs in the preterm period. These data can be used to counsel patients and to inform more detailed research into the mechanisms of trauma in pregnancy outcomes.

Positive blood alcohol is associated with reduced DVT in trauma

INTRODUCTION

Trauma patients exhibit a complex coagulopathy which is not fully understood and deep venous thrombosis (DVT) rates remain high. The effects of alcohol (EtOH) consumption on coagulopathy in trauma patients have not been studied. We hypothesized that acute EtOH intoxication would produce a relative hypocoagulable state as measured by thrombelastography (TEG) and would be associated with reduced DVT rates.

METHODS

Data were prospectively collected on 213 trauma patients at a level 1 trauma centre and analyzed in a retrospective secondary analysis. Thrombelastography (TEG), standard laboratory tests and ETOH levels were performed. If the level was positive, patients were grouped as EtOH+ and all patients were screened for DVT using a standard protocol. Statistical significance was p<0.05.

RESULTS

The EtOH+ group was predominantly male (76%), was younger (p<0.05), had a lower BMI (p<0.05), demonstrated a lower AIS extremity score (p<0.01) and was less likely to have a blunt injury (p<0.01) than the EtOH- group. Gender, ISS and other AIS scores were not significantly different. TEG values in the alcohol group demonstrated a relative hypocoagulable state that was associated with a reduced DVT incidence, 1.4% versus 16.2%, (p<0.01). This difference was not detected with conventional assays. A multivariate logistic regression was performed, controlling for common risk factors for DVT and a positive EtOH level on admission was independently associated with reduced DVT incidence.

CONCLUSIONS

Alcohol consumption is associated with a relative hypocoagulable state on TEG that is associated with a decreased DVT incidence. This difference is not detected by conventional assays.