Postpartum Emergency Department Research Articles

Postpartum Emergency Department Use Following Midwifery-Model vs Obstetrics-Model Care

(Abstracted from JAMA Netw Open. 2024;7:e248676) Midwives work in conjunction with obstetrics professionals and collaborate with other specialists when clinically indicated. Women receiving obstetrics care are often discharged quickly after birth and have only 1 follow-up visit at 6 weeks postpartum.

Massachusetts Medicaid ACO Program May Have Improved Care Use And Quality For Pregnant And Postpartum Enrollees.

Value-based care models, such as Medicaid accountable care organizations (ACOs), have the potential to improve access to and quality of care for pregnant and postpartum Medicaid enrollees. We leveraged a natural experiment in Massachusetts to evaluate the effects of Medicaid ACOs on quality-of-care-sensitive measures and care use across the prenatal, delivery, and postpartum periods. Using all-payer claims data on Medicaid-covered live deliveries in Massachusetts, we used a difference-in-differences approach to compare measures before (the first quarter of 2016 through the fourth quarter of 2017) and after (the third quarter of 2018 through the fourth quarter of 2020) Medicaid ACO implementation among ACO and non-ACO patients. After three years of implementation, the Medicaid ACO was associated with statistically significant increases in the probability of a timely postpartum visit, postpartum depression screening, and number of all-cause office visits in the prenatal and postpartum periods, with no changes in severe maternal morbidity, preterm birth, postpartum glucose screening, or prenatal or postpartum emergency department visits. Changes in cesarean deliveries were inconclusive. Results suggest that implementing Medicaid ACOs in the thirty-eight states without them could improve maternal health care outpatient engagement, but alone it may be insufficient to improve maternal health outcomes.

Quantifying the association between doula care and maternal and neonatal outcomes

BackgroundThe US suffers from an increasing rate of severe maternal morbidity, paired with a wide disparity in maternal health by race. Doulas are posited to be a useful resource to increase positive outcomes and decrease this disparity. ObjectiveEvaluate the association of doula care with a broad range of maternal and neonatal outcomes in various subpopulations. Study DesignRetrospective cohort of deliveries from 1/2021-12/2022 at a single institution receiving prenatal care. Exposure was receipt of doula care prenatally and at delivery. We evaluated both maternal (cesarean delivery, cesarean delivery of nulliparous, term, singleton, vertex infant, vaginal birth after cesarean (VBAC), gestational hypertension, preeclampsia, postpartum emergency department visit, readmission and attendance at postpartum office visit) and neonatal (neonatal intensive care unit admission, unexpected complications in term newborns, breastfeeding, preterm delivery, and intrauterine fetal growth restriction) outcomes. Because our institution previously employed targeted outreach, offering doula services to patients at highest risk, we utilized multiple methods to generate an appropriate comparison population. We conducted multivariate logistic regression and conditional regressions using propensity scores, modeling likelihood of doula care, to generate adjusted risk differences associated with doula care. Analyses were repeated in populations stratified by race (White/Black) then payor status (public/commercial). ResultsOur cohort included 17,831 deliveries; 486 with doula care and 17,345 without. Patients receiving doula care were more likely to self-report Black race, be publicly insured, and live in a more disadvantaged neighborhood. Regardless of analytic approach, for every 100 patients under doula care there were 15-34 more VBACs [adjRD 15.6 (95%CI: 3.8, 27.4); adjRD 34.2 (95%CI: 0.046, 68.0)] and 5-6 more patients attending a postpartum office visit [adjRD 5.4 (95%CI: 1.4, 9.5); adjRD 6.8 (95% CI:3.7, 9.9)] compared with those not receiving doula services.Infants born to these patients were 20% more like likely to be exclusively breastfed [adjRR 1.22 (95%CI: 1.07, 1.38)], and doula care was associated with 3-4 fewer preterm births [adjRD -3.8 (95%CI: -6.1, -1.5); -4.0 (95%CI: -6.2, -1.8)] for every 100 deliveries receiving doula care. Results were consistent regardless of race or insurance. Results were also consistent when doula care was redefined as having at least 3 prenatal encounters with a doula. ConclusionsDoula care was associated with more VBACs, attendance at postpartum office visit, breastfeeding, and fewer preterm deliveries. The effect of doula care was consistent across race and insurance status.

Postpartum Ambulatory Blood Pressure Patterns Following New-Onset Hypertensive Disorders of Pregnancy

After a hypertensive disorder of pregnancy, hypertension can worsen in the postpartum period following hospital discharge. Risk factors for ongoing hypertension and associated outcomes have not been well characterized. To identify risk factors and characterize outcomes for individuals with ongoing hypertension and severe hypertension following hospital discharge post partum through a hospital system's remote blood pressure (BP) management program. This cohort study involved a population-based sample of individuals with a new-onset hypertensive disorder of pregnancy (preeclampsia or gestational hypertension) and no prepregnancy hypertension who delivered between September 2019 and June 2021. Participants were enrolled in a remote BP monitoring and management program at a postpartum unit at a referral hospital. Data analysis was performed from August 2021 to January 2023. Inpatient postpartum BP categories. The primary outcomes were readmission and emergency department visits within the first 6 weeks post partum. Logistic regression was used to model adjusted odds ratios (aORs) and 95% CIs. Of 2705 individuals in the cohort (mean [SD] age, 29.8 [5.7] years), 2214 (81.8%) had persistent hypertension post partum after hospital discharge, 382 (14.1%) developed severe hypertension after discharge, and 610 (22.6%) had antihypertensive medication initiated after discharge. Individuals with severe hypertension had increased odds of postpartum emergency department visits (aOR, 1.85; 95% CI, 1.17-2.92) and hospital readmissions (aOR, 6.75; 95% CI, 3.43-13.29) compared with individuals with BP normalization. When inpatient postpartum BP categories were compared with outpatient home BP trajectories to inform optimal thresholds for inpatient antihypertensive medication initiation, there was significant overlap between postdischarge BP trajectories among those with inpatient systolic BP greater than or equal to 140 to 149 mm Hg and/or diastolic BP greater than or equal to 90 to 99 mm Hg and those with systolic BP greater than or equal to 150 mm Hg and/or diastolic BP greater than or equal to 100 mm Hg. This cohort study found that more than 80% of individuals with hypertensive disorders of pregnancy had ongoing hypertension after hospital discharge, with approximately 14% developing severe hypertension. These data support the critical role of remote BP monitoring programs and highlight the need for improved tools for risk stratification and consideration of liberalization of thresholds for medication initiation post partum.

Risk Factors for Emergency Department Visits and Readmissions for Postpartum Hypertension [ID 2683548

INTRODUCTION: Postpartum hypertension is a source of significant maternal morbidity and mortality. We aim to evaluate risk factors for postpartum emergency department (ED) visits and readmissions for hypertensive complications. METHODS: This was a retrospective cohort study of all birthing patients with peripartum hypertension at a single tertiary care center over a 5-year period (2017–2022). Maternal baseline and intrapartum characteristics were chart abstracted. Primary outcome of interest was postpartum ED visit or readmission (EDR) due to hypertensive complications. Patients who had EDR within 42 days of delivery were compared to those who underwent routine outpatient surveillance. This is IRB #14-001098. RESULTS: Of 16,162 patients who gave birth during the study period, 2,403 (14.9%) patients met the definition of peripartum hypertension. 218 (9.1%) presented to the ED or were readmitted for hypertension. Risk factors for EDR were as follows: maternal age greater than 40 years (22.9% versus 15.3%; P=.003), cesarean delivery (42.7% versus 35.8%; P=.044), chronic hypertension (37.2% versus 31.6%; P=.029), severe preeclampsia (32.6% versus 15.6%), p50% elevated blood pressures within the 24 hours prior to discharge (16.5% versus 11.9%; P=.046). CONCLUSION: Maternal age over 40, chronic hypertension, severe preeclampsia, prescription of antihypertensives on discharge, and elevated blood pressures leading up to discharge are associated with postpartum ED visits or readmissions for hypertension. Attention should be paid to these high-risk groups to reduce ED visits and readmissions.

Postpartum Emergency Department Use Following Midwifery-Model vs Obstetrics-Model Care

Emergency department (ED) use postpartum is a common and often-preventable event. Unlike traditional obstetrics models, the Ontario midwifery model offers early care postpartum. To assess whether postpartum ED use differs between women who received perinatal care in midwifery-model care vs in traditional obstetrics-model care. This retrospective population-based cohort study took place in Ontario, Canada, where public health care is universally funded. Participants included women who were low risk and primiparous and gave birth to a live baby in an Ontario hospital between 2012 and 2018. Data were collected from April 2012 to March 2018 and analyzed from June 2022 to April 2023. Perinatal care clinician, namely, a midwife or obstetrician. : Any unscheduled ED visit 42 days postpartum or less. Poisson regression models compared ED use between women with midwifery-model care vs obstetrics-model care, weighting by propensity score-based overlap weights. Among 104 995 primiparous women aged 11 to 50 years, those in midwifery-model care received a median (IQR) of 7 (6-8) postpartum visits, compared with 0 (0-1) visits among those receiving obstetrics-model care. Unscheduled ED visits 42 days or less postpartum occurred for 1549 of 23 124 women (6.7%) with midwifery-model care compared with 6902 of 81 871 women (8.4%) with traditional obstetrics-model care (adjusted relative risks [aRR], 0.78; 95% CI, 0.73-0.83). Similar aRRs were seen in women with a spontaneous vaginal birth (aRR, 0.71; 95% CI, 0.65-0.78) or assisted vaginal birth (aRR, 0.70; 95% CI, 0.59-0.82) but not those with a cesarean birth (aRR, 0.94; 95% CI, 0.86-1.03) or those with intrapartum transfer of care between a midwife and obstetrician (aRR, 0.94; 95% CI, 0.87-1.04). ED use 7 days or less postpartum was also lower among women receiving midwifery model care (aRR, 0.70; 95% CI, 0.65-0.77). In this cohort study, midwifery-model care was associated with less postpartum ED use than traditional obstetrics-model care among women who had low risk and were primiparous, which may be due to early access to postpartum care provided by Ontario midwives.

Virtual Obstetric Hospitalist Support for Obstetric Emergencies and Deliveries: The Mayo Clinic Experience.

Objective: To implement use of obstetric (OB) hospitalist telemedicine services (TeleOB) to support clinicians facing OB emergencies in low-resource hospital settings. Methods: TeleOB was staffed by OB hospitalists working at a tertiary maternity center. The service was available via real-time high-definition audio/video technology for providers at 17 outlying hospitals across a health system spanning two states. The initial 25 service activations are described. Results: TeleOB supported 17 deliveries, two postpartum emergency department (ED) consultations, and four antenatal ED consultations. In 10 of 17 (59%) deliveries, teleneonatology was jointly activated to support neonatal resuscitation. Sixteen (94%) deliveries occurred in multiparas, and five (29%) resulted from spontaneous preterm labor. Eighty percent (20/25) of activations occurred in facilities without maternity services. Conclusions: A TeleOB service staffed by OB hospitalists successfully supports hospitals in an integrated health care system. TeleOB is feasible for support of hospitals with no delivery facilities or with limited maternity care resources.

Hospital Encounters Within 1 Year Postpartum Across Insurance Types, Oregon 2012-2017.

Little is known about the timing and frequency of postpartum hospital encounters and postpartum visit attendance and how they may be associated with insurance types. Research on health insurance and its association with postpartum care utilization is often limited to the first 6 weeks. To assess whether postpartum utilization (hospital encounters within 1 year postpartum and postpartum visit attendance within 12 weeks) differs by insurance type at birth (Medicaid, high deductible health plans, and other commercial plans) and whether rates of hospital encounters differ by postpartum visit attendance and insurance status. Time-to-event analysis of Oregon hospital births from 2012 to 2017 using All Payer All Claims data. We conducted weighted Cox Proportional Hazard regressions and accounted for differences in insurance type at birth using multinomial propensity scores. Among 202,167 hospital births, 24.9% of births had at least 1 hospital encounter within 1 year postpartum. Births funded by Medicaid had a higher risk of a postpartum emergency department (ED) visit (hazard ratio: 2.05, 95% CI: 1.99, 2.12) and lower postpartum visit attendance (hazard ratio: 0.71, 95% CI: 0.70, 0.72) compared with commercial plans. Among Medicaid beneficiaries, missing the postpartum visit in the first 6 weeks was associated with a lower risk of subsequent readmissions (adjusted hazard ratio 0.77, 95% CI: 0.68, 0.87) and ED visits (adjusted hazard ratio: 0.87 (0.85, 0.88). Medicaid beneficiaries received more care in the ED within 1 year postpartum compared with those enrolled in other commercial plans. This highlights potential issues in postpartum care access.

Postpartum Emergency Department Visits and Risk Factors for Readmission [ID: 1363150

INTRODUCTION: Postpartum emergency department (ED) visits complicate 12% of births. We aimed to characterize trends in ED visits and risk factors for readmission. METHODS: This was a retrospective cohort study on postpartum ED visits within 42 days of delivery at a tertiary care center over 1 year. Readmitted patients were compared to those who remained outpatient as appropriate. IRB #14-001098. RESULTS: Of 3,084 deliveries, 138 (4.5%) patients presented to the ED for total 157 encounters. 17 (12.3%) patients presented more than once. 55 (35%) ED visits resulted in readmission, with 4 patients readmitted twice. Public insurance rates in the cohort were significantly higher than baseline (16.7% versus 8.5%, P=.001). Postpartum hypertension (HTN) was the most common reason for ED visits (40%) and had four times higher likelihood of being readmitted (adjusted odds ratio [aOR] 4.076, 95% CI 2.04–8.15, P<.001). Black women were six times more likely to be readmitted compared to other groups (aOR 6.53, 95% CI 1.26–33.88, P=.026). Coexistent psychiatric disease had lower likelihood of readmission (aOR 0.43, 95% CI 0.19–0.95, P=.037). Having more than one ED visit led to fivefold higher odds of readmission (aOR 5.05, 95% CI 1.66–15.32, P=.004). Median days from delivery to ED visit were 8 (interquartile range [IQR]: 5, 15). CONCLUSION: Seventy-three percent of presentations to the ED were within 2 weeks of delivery, and postpartum HTN was the leading cause. Black patients were more likely to be readmitted. Further studies are needed to evaluate whether earlier postpartum visits for high-risk groups may reduce ED visits and readmissions.

Patient Sociodemographics and Comorbidities and Birth Hospital Characteristics Associated With Postpartum Emergency Department Care

Postpartum emergency department (ED) visits may indicate poor access to care and risk for maternal morbidity. To identify patient and hospital characteristics associated with postpartum ED visit rates. This retrospective cohort study used data from the 2014 to 2016 New York State Inpatient Database and State Emergency Department Database. All obstetric discharges from acute care hospitals in New York State from January 1, 2014, through November 15, 2016, were included. Obstetric discharges in the inpatient database were linked to subsequent ED visits by the same patient in the ED database. Data were analyzed from February 2020 to August 2022. Patient characteristics assessed included age, race, insurance, home zip code income quartile, Charlson Comorbidity Index score, and obstetric risk factors. Hospital characteristics assessed included safety net status, teaching status, and status as a hospital disproportionally serving racial and ethnic minority populations. The primary outcome was any ED visit within 42 days of obstetric discharge. Multilevel logistic regression with 2-level nested mixed effects was used to account for patient and hospital characteristics and hospital-level clustering. Of 608 559 obstetric discharges, 35 299 (5.8%) were associated with an ED visit within 42 days. The median (IQR) birth hospital postpartum ED visit rate was 6.3% (4.6%-8.7%). The mean (SD) age was 28.4 (9.1) years, 53 006 (8.7%) were Asian patients, 90 675 (14.9%) were Black patients, 101 812 (16.7%) were Hispanic patients, and 275 860 (45.3%) were White patients; 292 991 (48%) were insured by Medicaid, and 290 526 (47.7%) had private insurance. Asian patients had the lowest postpartum ED visit rates (2118 ED visits after 53 006 births by Asian patients [3.99%]), and Black patients had the highest postpartum ED visit rates (8306 ED visits after 90 675 births by Black patients [9.15%]). Odds of postpartum ED visits were greater for Black patients (odds ratio [OR], 1.31; 95% CI, 1.26-1.35; P < .001) and Hispanic patients (OR, 1.19; 95% CI, 1.15-1.24; P < .001) relative to White patients; those with Medicare (OR, 1.55; 95% CI, 1.39-1.72; P < .001), Medicaid (OR, 1.37; 95% CI, 1.34-1.41; P < .001), or self-pay insurance (OR, 1.50; 95% CI, 1.41-1.59; P < .001) relative to commercial insurance; births that occurred at safety net hospitals (OR, 1.43; 95% CI, 1.37-1.51; P < .001) and hospitals disproportionately serving racial and ethnic minority populations (OR, 1.14; 95% CI, 1.08-1.20; P < .001); and births that occurred at hospitals with fewer than 500 births per year (OR, 1.25; 95% CI, 1.14-1.39; P < .001) relative to those with more than 2000 annual births. Adjusted odds of postpartum ED visits were lower after birth at teaching hospitals (OR, 0.82; 95% CI, 0.74-0.91; P < .001) and metropolitan hospitals (OR, 0.74; 95% CI, 0.65-0.85; P < .001). This cohort study found that Black and Hispanic patients experienced higher adjusted odds of postpartum ED visits across all hospital types, particularly at safety net hospitals and those disproportionately serving racial and ethnic minority populations . These findings support the urgent need to mitigate structural racism underlying maternal health disparities.

Increased rates of postpartum emergency department visits and inpatient readmissions in people with epilepsy

Increased rates of postpartum emergency department visits and inpatient readmissions in people with epilepsy

Association of Body Mass Index With the Use of Health Care Resources in Low-Risk Nulliparous Pregnancies After 39 Weeks of Gestation.

To compare health care medical resource utilization in low-risk nulliparous pregnancies according to body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) categories. This is a secondary analysis of a multicenter randomized controlled trial of induction of labor between 39 0/7 39 and 4/7 weeks of gestation compared with expectant management in low-risk nulliparous pregnant people, defined as those without standard obstetric indications for delivery at 39 weeks. Body mass index at randomization was categorized into four groups (lower than 25, 25-29, 30-39, and 40 or higher). The primary outcome of this analysis was time spent in the labor and delivery department from admission to delivery. Secondary outcomes included length of stay (LOS) postdelivery, total hospital LOS, and antepartum, intrapartum, and postpartum resource utilization, which were defined a priori. Multivariable generalized linear modeling and logistic regressions were performed, and 99% CIs were calculated. A total of 6,058 pregnant people were included in the analysis; 640 (10.6%) had BMIs of lower than 25, 2,222 (36.7%) had BMIs between 25 and 29, 2,577 (42.5%) had BMIs of 30-39, and 619 (10.2%) had BMIs of 40 or higher. Time spent in the labor and delivery department increased from 15.1±9.2 hours for people with BMIs of lower than 25 to 23.5±13.6 hours for people with BMIs of 40 or higher, and every 5-unit increase in BMI was associated with an average 9.8% increase in time spent in the labor and delivery department (adjusted estimate per 5-unit increase in BMI 1.10, 99% CI 1.08-1.11). Increasing BMI was not associated with an increase in antepartum resource utilization, except for blood tests and urinalysis. However, increasing BMI was associated with higher odds of intrapartum resource utilization, longer total hospital LOS, and postpartum resource utilization. For example, every 5-unit increase in BMI was associated with an increase of 26.1% in the odds of antibiotic administration, 57.6% in placement of intrauterine pressure catheter, 5.1% in total inpatient LOS, 31.0 in postpartum emergency department visit, and 23.9% in postpartum hospital admission. Among low-risk nulliparous people, higher BMI was associated with longer time from admission to delivery, total hospital LOS, and more frequent utilization of intrapartum and postpartum resources. ClinicalTrials.gov, NCT01990612.

A population-based analysis of postpartum acute care use among women with disabilities

Disability is common in reproductive-aged women, and as many as 1 in 8 pregnancies occur in women with a disability. Women with disabilities experience significant social and health disparities, and are at greater risk than their nondisabled counterparts for perinatal complications. Yet, few studies have examined their postpartum acute care use. To examine risks of postpartum emergency department visits and hospital admissions among women with and without physical, sensory, and intellectual/developmental disabilities. In this population-based study in Ontario, Canada, women with a singleton obstetrical delivery from 2003 to 2019 were classified into those with physical (n=155,500), sensory (n=49,338), intellectual/developmental (n=2650), and multiple disabilities (≥2 disabilities; n=9904), and women without disabilities (n=1,701,574). Primary outcomes were emergency department visits and hospital admissions 0 to 365 days after index delivery hospital discharge. Secondary outcomes were emergency department visits and hospital admissions by primary diagnosis (medical, psychiatric) and by timing (0-7, 8-42, 43-365 days postpartum). Adjusted relative risks comparing each disability group to those without disabilities were adjusted for age; parity; income quintile; rurality; immigrant/refugee status; prepregnancy chronic medical conditions, mental illness, and substance use disorders; and prenatal care provider type. Any postpartum emergency department visit occurred in 23.5% of women without a disability, with risks elevated in women with physical (32.9%; adjusted relative risk, 1.27; 95% confidence interval, 1.26-1.28), sensory (30.0%; adjusted relative risk, 1.16; 95% confidence interval, 1.15-1.18), intellectual/developmental (48.8%; adjusted relative risk, 1.38; 95% confidence interval, 1.33-1.44), and multiple disabilities (42.0%; adjusted relative risk, 1.44; 95% confidence interval, 1.41-1.48) compared with women without disabilities. Similarly, any postpartum hospital admission occurred in 3.0% of women without a disability, with elevated risks in women with physical (4.8%; adjusted relative risk, 1.37; 95% confidence interval, 1.34-1.40), sensory (4.0%; adjusted relative risk, 1.19; 95% confidence interval, 1.14-1.24), intellectual/developmental (9.6%; adjusted relative risk, 1.96; 95% confidence interval, 1.73-2.21), and multiple disabilities (7.3%; adjusted relative risk, 1.77; 95% confidence interval, 1.64-1.90). Results were consistent by primary diagnosis and timing in the postpartum period. Women with disabilities have elevated risk of emergency department visits and hospital admissions in the postpartum period, indicating greater postpartum morbidity, which requires attention through enhanced and extended follow-up across the postpartum period.

Postpartum Hospital Readmissions and Emergency Department Visits Among High-Risk, Medicaid-Insured Women in New York City.

Objectives: To describe the incidence of and characteristics associated with postpartum emergency department (ED) visits and hospital readmissions among high-risk, low-income, predominantly Black and Latina women in New York City (NYC). Methods: We conducted a secondary analysis of detailed survey and medical chart data from an intervention to improve timely postpartum visits among Medicaid-insured, high-risk women in NYC from 2015 to 2016. Among 380 women who completed surveys at baseline (bedside postpartum) and 3 weeks after delivery, we examined the incidence of having an ED visit or readmission within 3 weeks postpartum. We used logistic regression to examine unadjusted and adjusted associations between patient demographic, clinical, and psychosocial characteristics and the odds of postpartum hospital use. Results: In total, 12.8% (n = 48) of women reported an ED visit or readmission within 3 weeks postpartum. Unadjusted odds of postpartum hospital use were higher among women who self-identified as Black versus Latina, U.S. born versus foreign born, and English versus Spanish speaking. Clinical and psychosocial characteristics associated with increased unadjusted odds of postpartum hospital use included cesarean delivery, hypertensive disorders of pregnancy, and positive depression or anxiety screen, and we found preliminary evidence of decreased hospital use among women breastfeeding at three weeks postpartum. The odds of seeking postpartum hospital care remained roughly 2.5 times higher among women with hypertension or depression/anxiety in adjusted analyses. Conclusions: We identified characteristics associated with ED visits and hospital readmissions among a high-risk subset of postpartum women in NYC. These characteristics, including depressive symptoms and hypertension, suggest women who may benefit from additional postpartum support to prevent maternal complications and reduce health disparities.

Improving Postpartum Care: Identifying Opportunities to Reduce Postpartum Emergency Room Visits Among Publicly-Insured Women of Color.

Background/Objectives The purpose of this study was to explore the postpartum experiences of publicly-insured women of color, and identify how postpartum care can be improved to reduce hospital emergency department usage after delivery.MethodsWe conducted four focus groups with 18 publicly-insured women who primarily self-identified as Black and/or Latina and gave birth between June 1, 2019 and May 1, 2020. We used inductive qualitative analysis to identify prominent themes from focus group discussions.ResultsWe identified four domains: (1) lack of access to and communication with a medical team; (2) lack of preparation; (3) value of social support; and (4) participant-identified opportunities for improvement.Conclusions for PracticeThis study describes the postpartum experiences of publicly-insured women of color with the objective of identifying areas for intervention to reduce postpartum emergency department usage. Our findings suggest that focused efforts on enhancing continuity of care to increase healthcare access, strengthening patient-provider communication by training providers to recognize unconscious bias, increasing postpartum preparation by adapting teaching materials to an online format, and engaging women’s caregivers throughout the pregnancy course to bolster social support, may be beneficial.

Hospital Readmissions after Postpartum Emergency Department Visit

Up to 12% of pregnant patients have an emergency department (ED) visit within 6 weeks postpartum. However, little is known about the relationship between postpartum ‘treat-and-discharge’ ED visits and subsequent hospital readmission. Given that preventing hospital readmissions is central to postpartum quality improvement, we sought to examine the incidence of and risk factors for hospital readmission after a ‘treat-and-discharge’ postpartum ED visit.

Effect of mild preoperative thrombocytopenia on postpartum hemorrhage after cesarean deliveries

Thrombocytopenia at the time of delivery is considered as a risk factor for postpartum hemorrhage. However, platelet count thresholds for postpartum hemorrhage are variable and not extensively studied. This study aimed to examine whether mild thrombocytopenia is associated with an increased risk of postpartum hemorrhage among women undergoing cesarean delivery. This was a retrospective cohort study of all women who underwent cesarean delivery at a tertiary care hospital labor and delivery unit from September 2015 to June 2018. Women with normal platelet counts (≥150,000/µL) were compared with women with mild thrombocytopenia (100,000-149,000/µL). Women were excluded if they had moderate to severe thrombocytopenia (platelet count of <100,000/µL) or had received a platelet transfusion. The primary outcome was postpartum hemorrhage (quantitative blood loss of ≥1000 mL). Secondary outcomes included frequencies of red blood cell transfusion, wound complications (surgical site infections, dehiscence, or hematoma), and postpartum emergency department visits. Adjusted odds ratios with 95% confidence intervals were calculated, controlling for maternal age, gestational age, body mass index, scheduled cesarean delivery, hypertension, and preoperative hemoglobin level. Of 3133 women, 2799 (89.3%) had normal platelet levels, 298 (9.5%) had mild thrombocytopenia, and 36 (1.2%) had moderate to severe thrombocytopenia. There were no differences in the risks of postpartum hemorrhage, need for a red blood cell transfusion, wound complications, or postpartum emergency department visit comparing women with normal platelet counts with those with mild thrombocytopenia (24.6% vs 25.8% [adjusted odds ratio, 1.16; 95% confidence interval, 0.88-1.54]; 6.5% vs 6.7% [adjusted odds ratio, 1.34; 95% confidence interval, 0.80-2.24]; 4.5% vs 5.4% [adjusted odds ratio, 1.53; 95% confidence interval, 0.88-2.64]; 9.0% vs 10.7% [adjusted odds ratio, 1.37; 95% confidence interval, 0.92-2.03], respectively). Preoperative mild thrombocytopenia was not associated with postpartum hemorrhage, red blood cell transfusion, wound complications, or postpartum emergency department visits in women undergoing cesarean delivery.

1105 Edinburgh postnatal depression scores and postpartum healthcare utilization

To investigate the association of antepartum Edinburgh Postnatal Depression Scores (EPDS) on postpartum healthcare utilization. This was a secondary analysis of a randomized, non-blinded trial comparing the timing of postpartum visits (PPV) in a single academic center. Prospective variables collected included demographics, delivery outcomes, postpartum visits to the emergency department (ED) and clinic and EPDS in the antepartum period and immediately postpartum prior to discharge from the hospital. Univariable receiver operating characteristics (ROC) curves and Spearman correlation were utilized. Multivariable logistic regression was performed to adjust for confounders of attendance at the clinic and ED. Between November 2018 and March 2020, 256 patients were randomized, and outcome data are available for 250. The patient population had multiple underlying comorbidities, notably obesity (53%), diabetes (30%), mental health disorders (22%) and hypertensive disorders (21%). Eighteen women (7%) in the cohort utilized the ED within 30 days of delivery with the median attendance on postpartum day 10 (IQR 7.5-20). An elevated antepartum EPDS score >10 was more common among patients who used the ED compared to those who did not (47% vs 17%, p=0.004) (Table 1) with an area under the curve (AUC) of 0.648. (Figure 1) Inpatient EPDS were not associated with postpartum ED usage. A consult with a social worker during the delivery hospitalization was more common among those who utilized the ED (72% vs 29%, p<0.001) and was the strongest predictor after adjusting for confounders (aOR 5.43 [1.38-21.4]). There were no other demographic and clinical variables predictive of ED usage. Twenty one women (8%) presented to the clinic for an urgent postpartum visit and were more likely to have an antepartum EPDS >13 (31% vs 12%, p=0.027, aOR 7.93 [1.32-47.7]) An elevated EPDS in the antepartum time period is associated with postpartum emergency department use and urgent clinic visits. Close postpartum follow-up may be warranted for women with elevated EPDS during pregnancy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

122 Effect of preoperative thrombocytopenia on blood transfusion after cesarean deliveries

Thrombocytopenia at time of delivery is considered to be a risk factor for postpartum hemorrhage. However, platelet count thresholds for postpartum hemorrhage are variable and not extensively studied. We sought to assess if thrombocytopenia is associated with an increased risk of postpartum hemorrhage among women undergoing cesarean delivery. This was a retrospective cohort study of all women who delivered via cesarean delivery at a tertiary referral hospital from January 2012 to June 2018. Women with normal platelet counts (≥150 k/microL) were compared to women with mild thrombocytopenia (100 – 149 k/microL) and women with severe thrombocytopenia (<100 k/microL). Women who received preoperative platelet transfusion were excluded. The primary outcome was red blood cell transfusion. We also examined postpartum hemorrhage (blood loss ≥1000 mL), wound complications (surgical site infections, dehiscence, hematoma), and postpartum emergency department visit. Adjusted odds ratios (aOR) with 95% confidence intervals (95%CI) were calculated, controlling for gestational age, body mass index (kg/m2), scheduled cesarean, and hypertension. We evaluated 7, 177 women who underwent cesarean delivery, of whom 6,431 (89.6%) had normal platelet levels, 675 (9.4%) had mild thrombocytopenia, and 71 (1.0%) had severe thrombocytopenia. Demographics are presented in Table 1. Compared to women with a normal platelet count, women with mild and severe thrombocytopenia did not have increased odds of red blood cell transfusion (normal 5.4%; mild thrombocytopenia 6.4% [aOR 1.16; 95%CI 0.83-1.62]; severe thrombocytopenia 12.7% [aOR 1.44; 95%CI 0.65-3.18]). Similarly, compared to women with a normal platelet count, women with mild and severe thrombocytopenia did not have increased odds of secondary outcomes (Table 2). Preoperative mild and severe thrombocytopenia is not associated with blood transfusion, postpartum hemorrhage, wound complications, and postpartum emergency department visit in women undergoing cesarean delivery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Emergency department use among postpartum women with mental health disorders

BackgroundMental health disorders are becoming more recognized in pregnancy. Whether mental health disorders are associated with health services utilization after child birth is not completely understood.ObjectiveThis study aimed to investigate postpartum emergency department use within 30 days of delivery among women with preexisting mental health disorders during pregnancy.Study DesignThis was a retrospective cohort study evaluating emergency department use among postpartum women with or without mental health disorders who delivered at an academic center between January 2014 and June 2018. Demographic and outcome data were medical record abstracted and analyzed. Multivariate regression was performed to adjust for covariates.ResultsDuring the study period, 13,605 women delivered at the institution, 2355 of whom (17.3%) had an underlying mental health disorder. The primary diagnoses of mental health disorder were anxiety (48.8%), depression (34.8%), substance use disorder (11.4%), bipolar disorder (3.4%), psychosis (0.7%), and other (0.8%). There were a total of 565 emergency department visits within 30 days of delivery. Women who presented to the emergency department after delivery were more likely to have public insurance, identify as black or Asian, and have an underlying mental health disorder. Among women with mental health disorders, 155 (6.6%) used the emergency department within 30 days of their delivery compared with 410 (3.6%) of patients without mental health disorder (adjusted odds ratio, 1.74; 95% confidence interval, 1.42–2.13; P<.001). When assessing the risk of emergency department usage per the type of mental health disorder, anxiety (adjusted odds ratio, 1.73; 95% confidence interval, 1.31–2.27) and depression (adjusted odds ratio, 2.13; 95% confidence interval, 1.59–2.86) carried the highest risk. Compared with women without mental health disorders, women with underlying mental health disorders had more presentations for hypertension (15.5% vs 11.2%) and psychiatric evaluations (4.5% vs 0.2%; both P<.001).ConclusionWomen with mental health disorders use the emergency department during the postpartum period for psychiatric and obstetrical reasons more frequently than women without mental health disorders. Increased surveillance, treatment, and follow-up during pregnancy and the early postpartum period may be warranted for this high-risk population.