Pregnancy-related Hospitalizations Research Articles

Heart Failure in Pregnant Women: A Concern Across the Pregnancy Continuum.

Heart failure (HF) is a leading cause of maternal morbidity and mortality in the United States, but prevalence, correlates, and outcomes of HF-related hospitalization during antepartum, delivery, and postpartum periods remain unknown. The objective was to examine HF prevalence, correlates, and outcomes among pregnancy-related hospitalizations among women 13 to 49 years of age. We used the 2001 to 2011 Nationwide Inpatient Sample. Rates of HF were calculated by patient and hospital characteristics. Survey logistic regression was used to estimate adjusted odds ratios representing the association between HF and each outcome, stratified by antepartum, delivery, and postpartum periods. Joinpoint regression was used to describe temporal trends in HF and in-hospital mortality. Over 50 million pregnancy-related hospitalizations were analyzed. The overall rate of HF was 112 cases per 100 000 pregnancy-related hospitalizations. Although postpartum encounters represented only 1.5% of pregnancy-related hospitalizations, ≈60% of HF cases occurred postpartum, followed by delivery (27.3%) and antepartum (13.2%). Among postpartum hospitalizations, there was a significant 7.1% (95% confidence interval, 4.4-9.8) annual increase in HF from 2001 to 2006, followed by a steady rate through 2011. HF rates among antepartum hospitalizations increased on average 4.9% (95% confidence interval, 3.0-6.8) annually from 2001 to 2011. Women with a diagnosis of HF were more likely to experience adverse maternal outcomes, as reflected by outcome-specific adjusted odds ratios during antepartum (2.7-25), delivery (6-195), and postpartum (1.5-6.6) periods. HF is associated with increased risk of maternal mortality and morbidities. During hospitalization, high-risk mothers need to be identified and surveillance programs developed before discharge.

Severe pre-eclampsia among pregnant women with sickle cell disease and HIV

The relationship between sickle cell disease (SCD) and severe pre-eclampsia is poorly established. It is also unknown whether the occurrence of HIV infection among women with SCD modifies their risk level for severe pre-eclampsia. We hypothesized that pregnant women with SCD are at an elevated risk for severe pre-eclampsia as a result of heightened endothelial damage; and the combination of SCD-HIV augments the inflammatory processes of endothelial damage leading to amplified risk for severe pre-eclampsia. We analyzed more than 57 million pregnancy-related hospitalizations and births in the US from January 1, 2002 through December 31, 2014. We applied multivariable survey logistic regression to generate odds ratios for the association between SCD, HIV and SCD-HIV status and severe pre-eclampsia with adjustment for potential confounders. Of the total 57,326,459 pregnant women, 57,198,505 (99.78%) did not have SCD or HIV, 73,064 (12.7 per 10,000) had HIV only, 54,890 (9.58 per 10,000) had SCD only and 222 (0.39 per 100,000) had both SCD and HIV. Mothers with SCD and HIV-SCD experienced a significant elevation in risk for severe pre-eclampsia of about 60% (OR = 1.61; 95% CI = 1.44, 1.79) and of more than 300% (OR = 4.28; 95% CI = 1.35, 13.62) respectively. In the largest study on SCD and pre-eclampsia in the world, we established SCD to be strongly associated with severe pre-eclampsia. Another unique finding is the synergistic effect of amplified risk for severe pre-eclampsia among mothers with the combined SCD-HIV status.

Hospital length of stay and cost burden of HIV, tuberculosis, and HIV-tuberculosis coinfection among pregnant women in the United States

We sought to determine hospital length of stay (LOS) and cost burden associated with hospital admissions among pregnant women with HIV monoinfection, tuberculosis (TB) monoinfection, or HIV-TB coinfection in the United States. Analysis covered the period from 2002-2014 using data from the Nationwide Inpatient Sample. Relevant ICD-9-CM codes were used to determine HIV and TB status. Costs associated with hospitalization were calculated and adjusted to 2010 dollars using the medical care component of the Consumer Price Index. We found modest annual average reduction in HIV, TB, and HIV-TB coinfection rates over the study period. The mean LOS was lowest among mothers free of HIV or TB disease and highest among those with HIV-TB coinfection. The average LOS among mothers diagnosed with TB monoinfection was 60% higher than for those with HIV monoinfection. The cost associated with pregnancy-related hospital admissions among mothers with HIV was approximately 30% higher than disease-free mothers, and the cost more than doubled among patients with TB monoinfection or HIV-TB coinfection. TB significantly increased hospital care cost among HIV-positive and HIV-negative pregnant women.

State Medicaid Coverage of Medically Necessary Abortions and Severe Maternal Morbidity and Maternal Mortality.

To estimate the association between state Medicaid coverage of medically necessary abortion and severe maternal morbidity and in-hospital maternal mortality in the United States. We used data on pregnancy-related hospitalizations from the Nationwide Inpatient Sample from 2000 to 2011 (weighted n=38,016,845). State-level Medicaid coverage of medically necessary abortion for each year was determined from Guttmacher Institute reports. We used multivariable logistic regression to examine the association between state Medicaid coverage of abortion and severe maternal morbidity and in-hospital maternal mortality, overall and stratified by payer. The unadjusted rate of severe maternal morbidity was lower among Medicaid-paid hospitalizations in states with Medicaid coverage of medically necessary abortion relative to those in states without such coverage (62.4 compared with 69.3 per 10,000). Among Medicaid-paid hospitalizations in states with Medicaid coverage of medically necessary abortion, there were 8.5 per 10,000 fewer cases (95% confidence interval [CI] 4.0-16.5) of severe maternal morbidity in adjusted analyses relative to those in states without such Medicaid coverage. Similarly, there were 10.3 per 10,000 fewer cases (95% CI 3.5-17.2) of severe maternal morbidity in adjusted analyses among private insurance-paid hospitalizations in states with Medicaid coverage of medically necessary abortion relative to those in states without such Medicaid coverage. The adjusted rate of in-hospital maternal mortality was not different for Medicaid-paid hospitalizations in states with and without Medicaid coverage of medically necessary abortion (9.2 and 9.0 per 100,000, respectively) nor for private insurance-paid hospitalizations (5.6 and 6.1 per 100,000, respectively). State Medicaid coverage of medically necessary abortion was associated with an average 16% decreased risk of severe maternal morbidity. An association between state Medicaid coverage of medically necessary abortion and a reduced risk of severe maternal morbidity was observed in women covered by both Medicaid and private insurance. Results suggest that Medicaid coverage of medically necessary abortion is not harmful to maternal health.

National In-Hospital Outcomes of Pregnancy in Women With Single Ventricle Congenital Heart Disease

Most patients with single ventricle (SV) congenital heart disease are expected to survive to adulthood. Women with SV are often counseled against pregnancy; however, data on pregnancies in these women are lacking. We sought to evaluate in-hospital outcomes of pregnancy in women with SV. We used nationally representative data from the 1998 to 2012 National Inpatient Sample to identify women ≥18years of age admitted to the hospital with International Classification of Diseases-9th Revision codes for an intrauterine pregnancy and a diagnosis of hypoplastic left heart syndrome, tricuspid atresia, or common ventricle. A matched comparison group without a diagnosis of congenital heart disease or pulmonary hypertension was identified from the database. National estimates of hospitalizations were calculated. Length of stay, hospital charges, and complications were analyzed and compared between groups. Charge data were adjusted to 2012 dollars. There were 282 admissions of pregnant women with SV (69% with deliveries) and 1,405 admissions in the control group (88% with deliveries). Vaginal delivery was more common in SV (74% vs 71%, p <0.001). Length of stay (4.1 ± 0.91 vs 2.8 ± 0.18 days, p <0.001) and charges ($30,787 ± 8,109 vs $15,536 ± 1,006, p <0.0001) were higher in the SV group. Complications occurred in most SV admissions and were more common in the SV group than in the control group. No deaths occurred. Cardiovascular complications occurred in 25% of pregnancy-related hospitalizations, although in-hospital pregnancy-related death is rare. Vaginal delivery is common in these patients. These data suggest that pregnancy and vaginal delivery can be tolerated in women with SV, although the risk for a cardiovascular event is significantly higher than in the general population.

Abstract WP204: Increase in Rates of Pregnancy Hospitalizations With Concomitant Stroke 2000 to 2012: The National Inpatient Sample

Introduction: There has been limited publication of temporal trends in rates of stroke during pregnancy. The HCUP National Inpatient Sample (NIS) is a set of longitudinal databases, originally encompassing all discharges from 20% of the available community non-rehabilitation hospitals each year. In the year 2000, 994 hospitals yielded 7,450,992 unweighted discharge records. Beginning in 2012, the most recent year included in this analysis, the sampling scheme changed to a 20% random sample of discharges from each participating hospital. This resulted in data from 4,378 hospitals, yielding 7,296,968 unweighted discharge records. Methods: Using pregnancy related discharges in patients greater than 14 years(y) of age from the NIS between 2000 and 2012, we set out to determine if rates of pregnancy related hospital stays which included a diagnosis of stroke, have changed over time. Stroke was defined by ICD-9 codes of 430.xx for subarachnoid hemorrhage (SAH), 431.xx and 432.9x for intracranial hemorrhage (ICH); and 433.x1, 434.x1, and 436.xx for ischemic stroke (IS). Pregnancy was defined by ICD-9 codes of 630.xx to 679.xx (undelivered), and DRG (v18 or v24) between 370 and 375 or ICD9 V27.x (delivered). Appropriate NIS discharge weights were used to estimate national rates and determine variance. Stroke rates are reported per 100,000 pregnancy related discharges. Trends over time were tested. Results: Rates for stroke increased from 15 (4 ICH, 4 SAH, 7 IS) in 2000, to 26 (6 SAH, 8 ICH, 12 IS) in 2012 (p&lt;.001). Stroke in women who delivered during the hospitalization increased from 4.8 to 6.6 (ns), while in those hospitalized during gestation and discharged undelivered, the stroke rate increased from 103 to 223 (p&lt;.001). The increase was predominately in IS. Rates increased from 12 to 18 for women aged &lt; 25 y; from 16 to 27 for women between 25 and 34 y; and from 28 to 47 for women 35 y and older, over the 12 year period. Conclusion: The diagnosis of stroke in pregnancy related hospital stays increased by 73% between 2000 and 2012. The reason for this could be changes in coding or diagnoses, or a true increase in stroke incidence, but further study is needed.

Younger and Sicker: Comparing Micronesians to Other Ethnicities in Hawaii.

We compared the age at admission and the severity of illness of hospitalized Micronesians with 3 other racial/ethnic groups in Hawaii. With Hawaii Health Information Corporation inpatient data, we determined the age at admission and the severity of illness for 162,152 adult, non-pregnancy-related hospital discharges in Hawaii from 2010 to 2012. We performed multivariable linear regression analyses within major disease categories by racial/ethnic group. We created disease categories with all patient refined-diagnosis related groups. Hospitalized Micronesians were significantly younger at admission than were comparison racial/ethnic groups across all patient refined-diagnosis related group categories. The severity of illness for Micronesians was significantly higher than was that of all comparison racial/ethnic groups for cardiac and infectious diseases, higher than was that of Whites and Japanese for cancer and endocrine hospitalizations, and higher than was that of Native Hawaiians for substance abuse hospitalizations. Micronesians were hospitalized significantly younger and often sicker than were comparison populations. Our results will be useful to researchers, state governments, and hospitals, providers, and health systems for this vulnerable group.

O60. Treatment of hypertension in pregnancy

Several international (2013 ESH/ESC guidelines, AHA/ISH guidelines, JNC-8) and national (NICE, French, Canadian, Hungarian, Chinese) guidelines have been published recently with recommendations for management of hypertension in pregnancy. Data-based opinions onantihypertensive treatment initiation and target blood pressure (BP), and drugs of choice are not similarly described in these guidelines. Main objectives of the presentation are to summarise data of the relevant literature. Review of the recently published guidelines. Treatment initiation: in addition to life-style changes, there is consensus that drug treatment of severe hypertension (⩾160/110 mmHg) in pregnancy is indicated and beneficial. The suggestion, in the 2007 European Society of Hypertension (ESH) and European Society of Cardiology (ESC) Guidelines, for considering treatment in all pregnant women with persistent elevation of BP ⩾150/95 mmHg is supported by recent US data, showing an increasing trend in the rate of pregnancy-related hospitalizations with stroke — especially during the postpartum period — and by an analysis of stroke victims with severe pre-eclampsia and eclampsia. However, the benefits of antihypertensive therapy are uncertain in pregnant women with mildly to moderately elevated blood pressure (⩽160/110 mmHg), either pre-existing or pregnancy-induced, except for a lower risk of developing severe hypertension. Despite lack of evidence, the Task Force of 2013 ESH/ESC Guidelines reconfirms that physicians should consider early initiation of antihypertensive treatment at values of BP ⩾140/90 mmHg in women with (i) gestational hypertension (with or without proteinuria), (ii) pre-existing hypertension with the superimposition of gestational hypertension or (iii) hypertension with asymptomatic organ damage (OD) or symptoms at any time during pregnancy. Target blood pressure: Guidelines mostly agree on that BP should be normalised (to <140/90 mmHg) in pregnant women with hypertension. Drug treatment: Drug treatment can be considered in pregnant women with persistent elevation of BP ⩾150/95 mmHg, and in those with BP ⩾140/90 mmHg in the presence of gestational hypertension, subclinical OD or symptoms due to increased BP. The recommendations to use methyldopa, labetalol and nifedipine as the only calcium antagonist really tested in pregnancy was confirmed in recent European and US guidelines. Beta-blockers (possibly causing foetal growth retardation if given in early pregnancy) anddiuretics (in pre-existing reduction of plasma volume) should be used with caution, only if other indications exist (e.g. ischemic heart disease, severe tachycardia, excess fluid retention). All agents interfering with the renin-angiotensin system (ACE inhibitors, angiotensin AT-1 receptor blockers, renin inhibitors) should absolutely be avoided. In emergency (pre-eclampsia), intravenous labetalol is the drug of choice with sodium nitroprusside (only for short term) or nitroglycerin in intravenous infusion being other options. According to recent guidelines, in the absence of randomised clinical trials recommendations how hypertension should be treated in pregnant women, can only be guided by experts’ opinion based on case reports and their meta-analyses.

Compliance with pregnancy prevention plan recommendations in 8672 French women of childbearing potential exposed to acitretin.

Acitretin is an oral synthetic aromatic analogue of retinoic acid available in most European countries since 1988. It is mainly used to treat severe psoriasis. Like all systemic retinoids, acitretin is teratogenic. Strict pregnancy prevention is required in women of childbearing potential who use acitretin. This study assessed compliance with Pregnancy Prevention Plan (PPP) recommendations, specifically looking at compliance with pregnancy testing (PT) and pregnancy occurrence. A cohort of 8672 women aged 15-49 years initiating acitretin treatment from 1 January 2007 through 31 December 2013 was identified using French SNIIRAM (administrative claims data) and PMSI (hospitalisations data) databases. Pregnancy tests (PTs) were identified from reimbursed serum βHCG and urine laboratory PTs. To satisfy PT criteria, patients who started treatment had to undergo a PT within 3 days before acitretin was dispensed. Pregnancies were identified by a pregnancy-related hospital stay or an outpatient medical abortion. A PT was performed in only 12% of women starting treatment and was rarely performed during treatment or during the 24 months following discontinuation of treatment. Compliance with PPP recommendations although poor appeared to be better among private dermatologists, as a PT was performed for 16% of treatment initiations (vs. 4% for general practitioners, p < 0.001). Moreover, 470 pregnancies were reported corresponding to 27 pregnancies per 1000 person-years at risk of teratogenicity. This study highlights poor compliance with acitretin PPP recommendations in France. Physicians and pharmacists must more rigorously apply the acitretin PPP recommendations, and patients must be better informed about acitretin's risk of teratogenicity.

Albumin Decrease Is Associated with Spontaneous Preterm Delivery within 48 h in Women with Threatened Preterm Labor

Threatened preterm labor (TPTL) accounts for ∼30% of pregnancy-related hospital admissions. Maternal peripheral leukocytes can be used to monitor a variety of physiological processes occurring in the body. Two high-throughput mass spectrometry methodologies, SWATH and iTRAQ, were used to study differentially expressed peripheral blood leukocyte lysate proteins in symptomatic women admitted for TPTL who had a preterm birth within 48 h (n = 16) and those who did not (n = 24). The SWATH spectral library consisted of 783 proteins. SWATH methodology quantified 258 proteins (using ≥2 peptides) and 5 proteins (ALBU, ANXA6, HNRPK, HSP90A, and PDIA1) were differentially expressed (p < 0.05, Mann-Whitney U). iTRAQ workflow identified 765 proteins; 354 proteins were quantified and 14 proteins (MIF, UBIQ, HXK3, ALBU, HNRPD, ST1A2, RS15A, RAP1B, CAN1, IQGA2, ST1A1, COX5A, ADDA, and UBQL1) were significantly different between the two groups of women (p < 0.05, Mann-Whitney U). Albumin was the only common differentially expressed protein in both SWATH (28% decrease) and iTRAQ studies (45% decrease). This decrease in albumin was validated using ELISA (11% decrease, p < 0.05, Mann-Whitney U) in another 23 TPTL women. This work suggests that albumin is a broad indicator of leukocyte activation with impending preterm birth and provides new future work directions to understand the pathophysiology of TPTL.

National trends in maternal use of opioid drugs among pregnancy-related hospitalizations in the United States, 1998 to 2009.

The aim of this study is to describe national trends for opioid use among pregnancy-related hospitalizations from 1998 to 2009. Using the Nationwide Inpatient Sample, we identified hospital discharge records associated with the diagnoses codes for the use of opioids for all eligible pregnancy-related inpatient admissions between 1998 and 2009. Joinpoint regression modeling was used to describe changes in trend of pregnancy-related opioid use. The main outcome measure was the annual percent change for opioids use among pregnancy-related hospitalizations. From 1998 to 2009, opioid use was documented in 138,224 of 55,781,966 pregnancy-related inpatient hospitalizations (25 cases per 10,000 discharges). A statistically significant downward trend occurred from 1998 to 2001, whereas from 2002 to 2009 there was a statistically significant upward trend. The increasing trend in opioid use from 2002 to 2009 is notably higher for whites compared with blacks and Hispanics. Our findings highlight the continuous need to monitor opioids use and to revise prescription guidelines, practices, and regulatory mechanisms to curtail the progression of the increasing opioids use during pregnancy. It is critical that health care providers weight the benefits of these medications along with their potential risks when discussing analgesic treatment options with pregnant women.

The influence of ethnicity on the outcomes of violence in pregnancy

Aim. To investigate the influence of ethnicity on immediate and long-term (five years post-partum) foetal, maternal and injury-related outcomes.Methods. A retrospective, population-based study analysing maternal discharge records linked to birth/death certificates for women aged 25 years and under. Discharge records were grouped according to ethnicity (Maori and non-Maori) and as follows: (1) a pregnancy-related hospital admission, but no associated or subsequent assault recorded (pregnant only); (2) an assault-related hospital admission event after the pregnancy, but within five years of the index pregnancy (assault after pregnancy); and (3) an assault recorded within the same hospital admission event as the pregnancy (assault during pregnancy). Generalised linear models for the binomial family were conducted to explore increased risk ratios of pregnancy-related and subsequent injury outcomes depending on ethnicity and group assignment.Results. Compared with the pregnancy-only group, rate ratios (RRs) for maternal and foetal outcomes were higher in the assault after pregnancy group and the assault during pregnancy group. For injury outcomes in the five years after the injury event, RRs for the assault after pregnancy group exceeded both the pregnancy-only and the assault during pregnancy groups. RRs for non-Maori women assaulted after pregnancy were higher for injury hospitalisations, fracture and intracranial injury than those for Maori women.Conclusion. Given that Maori women experience a higher prevalence of severe intimate partner violence and more difficulties accessing health care, we suggest that the findings highlight potential problems for health care access for Maori women experiencing violence.

Immediate and long‐term outcomes of assault in pregnancy

We examined the immediate and long-term health outcomes of hospitalised pregnancy-related assault. A retrospective review of hospital records was conducted using data from the New Zealand Ministry of Health's National Minimum Data Set of hospital discharges. The hospital records of pregnant women admitted to a public hospital in New Zealand between 2001 and 2006 were included in this investigation. Unique identifiers were used to identify the index pregnancy event, subsequent discharge events and mortality for fiveyears after the index event. Discharge records were grouped as follows: pregnancy-related hospital admission, but no associated or subsequent assault recorded (pregnant only); an assault-related hospital admission event after the pregnancy, but within fiveyears of the index pregnancy (assault after pregnancy); an assault recorded within the same hospital admission event as the pregnancy (assault during pregnancy). Generalised linear models for the binomial family were conducted to explore increased risk ratios of adverse maternal, fetal and subsequent injury outcomes depending on group assignment. Compared with the pregnancy-only group, the assault after pregnancy and assault during pregnancy groups had increased risk ratios for death, preterm labour, antepartum haemorrhage, infectious complication, spontaneous abortion and stillbirth. Assault during pregnancy substantially increased the risks for a number of adverse maternal and fetal outcomes. The identification of women who live in a violent relationship and the provision of adequate social support to these women may reduce the risks of subsequent injury and adverse maternal and fetal outcomes.

Abstract W P321: Stroke Outcomes and Usage of IV Alteplase During Pregnancy in the Nationwide Inpatient Sample 2005-2010

Background: Although alarmingly increasing trends of stroke in pregnancy has been reported in the US, few studies have investigated clinical outcomes, including outcomes of IV alteplase (tPA) treatment among pregnant women. Methods: Data was abstracted from the Nationwide Inpatient Sample, an all-payer inpatient care database. We identified pregnancy-related hospitalizations from 2005-2010 by ICD-9-CM diagnostic codes. We extracted diagnoses of acute ischemic stroke (AIS), intracerebral (ICH) and subarachnoid (SAH) hemorrhage, transient ischemic attack, cerebral venous thrombosis (CVT), unspecified, and other pregnancy-related complications. We also identified pregnant women with AIS who received IV tPA. Clinical outcomes included length of stay (LOS), discharge disposition, and in-hospital mortality. Results: An estimated 18,392 pregnant women were diagnosed with stroke from 2005-2010. CVT (26.8%) and hemorrhagic (ICH and SAH) stroke (22.8%) were the most common types of stroke, with about 20% of all stroke reported as unspecified in 2010. Mean LOS ranged from 6.5-7.2 days; linear regression did not reveal significant trends in LOS over time. The most common pregnancy-related stroke risk factors included hypertension (30.2%) and pre-eclampsia (13.4%). Decreasing trend of discharge home (from 78.3 to 72.6%, p=0.09) and increasing mortality rate (from 1.8% to 4.0% p for linear trend=0.02) were observed from 2005 to 2010. Of the estimated 70 pregnant AIS patients treated with IV tPA, LOS ranged 4-28 days; 78.6% were discharged home, 14.3% to skilled nursing facility, and 7.1% died. Conclusions: Stroke remains a serious complication in pregnancy, and mortality is increasing. Usage of tPA for AIS during pregnancy is minimal, with increased mortality compared to all strokes in pregnancy. Research efforts are needed to improve stroke outcomes during pregnancy.

Hospitalizations Following Living Donor Nephrectomy in the United States

Living donors represented 43% of United States kidney donors in 2012. Although research suggests minimal long-term consequences of donation, few comprehensive longitudinal studies for this population have been performed. The primary aims of this study were to examine the incidence, risk factors, and causes of rehospitalization following donation. State Inpatient Databases (SID) compiled by the Agency for Healthcare Research and Quality were used to identify living donors in four different states between 2005 and 2010 (n=4524). Multivariable survival models were used to examine risks for rehospitalization, and patient characteristics were compared with data from the Scientific Registry of Transplant Recipients (SRTR). Outcomes among patients undergoing appendectomy (n=200,274), cholecystectomy (n=255,231), and nephrectomy for nonmetastatic carcinoma (n=1314) were contrasted. The study population was similar to United States donors (for SRTR and SID, respectively: mean age, 41 and 41 years; African Americans, 12% and 10%; women, 60% and 61%). The 3-year incidence of rehospitalization following donation was 11% for all causes and 9% excluding pregnancy-related hospitalizations. After censoring of models for pregnancy-related rehospitalizations, older age (adjusted hazard ratio [AHR], 1.02 per year; 95% confidence interval [95% CI], 1.01 to 1.03), African American race (AHR, 2.16; 95% CI, 1.54 to 3.03), depression (AHR, 1.88; 95% CI, 1.12 to 3.14), hypothyroidism (AHR, 1.63; 95% CI, 1.06 to 2.49), and longer initial length of stay were related to higher rehospitalization rates among donors. Compared with living donors, adjusted risks for rehospitalizations were greater among patients undergoing appendectomy (AHR, 1.58; 95% CI, 1.42 to 1.75), cholecystectomy (AHR, 2.25; 95% CI, 2.03 to 2.50), and nephrectomy for nonmetastatic carcinoma (AHR, 2.95; 95% CI, 2.58 to 3.37). Risks for rehospitalizations were higher among African Americans than whites in each of the surgical groups. The SID is a valuable source for evaluating characteristics and outcomes of living kidney donors that are not available in traditional transplant databases. Rehospitalizations following donor nephrectomy are less than seen with other comparable surgical procedures but are relatively higher among donors who are older, are African American, and have select comorbid conditions. The increased risks for rehospitalizations among African Americans are not unique to living donation.

Trends in venous thromboembolism among pregnancy-related hospitalizations, United States, 1994-2009

The purpose of this study was to evaluate national trends in the rate of pregnancy-related hospitalizations for venous thromboembolism (VTE) from 1994-2009 and to estimate the prevalence of comorbid conditions among these hospitalizations. An estimated 64,413,973 pregnancy-related hospitalizations among women 15-44 years old were identified in the 1994-2009 Nationwide Inpatient Sample. Trends in VTE-associated pregnancy hospitalizations were evaluated with the use of variance-weighted least squares regression. Chi-square tests were used to assess changes in prevalence of demographics and comorbid conditions, and multivariable logistic regression was used to evaluate the likelihood of VTE during the study period after adjustment for comorbid conditions. Antepartum, delivery, and postpartum hospitalizations were evaluated separately and reported in 4-year increments. From 1994-2009, there was a 14% increase in the rate of overall VTE-associated pregnancy hospitalizations; antepartum and postpartum hospitalizations with VTE increased by 17% and 47%, respectively. Between 1994-1997 and 2006-2009, the prevalence of hypertension and obesity doubled among all VTE-associated pregnancy hospitalizations; significant increases in diabetes mellitus and heart disease were also noted. A temporal increase in the likelihood of a VTE diagnosis in pregnancy was observed for antepartum hospitalizations from 2006-2009 when compared with 1994-1997 (adjusted odds ratio, 1.62; 95% confidence interval, 1.48-1.78). There has been an upward trend in VTE-associated pregnancy hospitalizations from 1994-2009 with concomitant increases in comorbid conditions. Clinicians should have a heightened awareness of the risk of VTE among pregnant women, particularly among those with comorbid conditions, and should have a low threshold for evaluation in women with symptoms or signs of VTE.

Age, mode of conception, health service use and pregnancy health: a prospective cohort study of Australian women

BackgroundThere is limited evidence about the ways in which maternal age and mode of conception interact with psychological, sociodemographic, health and health service factors in governing pregnancy health. The aim of this study was to establish in what ways maternal age and mode of conception are associated with, health behaviours, health service use and self-rated physical and mental health during pregnancy.MethodA prospective cohort study was conducted in a collaboration between universities, infertility treatment services and public and private obstetric hospitals in Melbourne and Sydney, Australia,. Consecutive cohorts of nulliparous English-literate women at least 28 weeks pregnant who had conceived through ART (ARTC) or spontaneously (SC) in three age-groups: 20–30; 31–36 and at least 37 years were recruited. Data were obtained via structured individual telephone interviews and self-report postal questionnaires at recruitment and four months postpartum. Study-specific questions assessed: sociodemographic characteristics; reproductive health; health behaviours and health service use. Standardized instruments assessed physical health: SF 12 Physical Component Score (PCS) and mental health: SF12 Mental Component Score (MCS); State Trait Anxiety Inventory and Edinburgh Postnatal Depression Scale. The main outcome measures were the SF 12 PCS, SF12 MCS scores and pregnancy-related hospital admissions.ResultsOf 1179 eligible women 791 (67%) participated, 27 had fertility treatment without oocyte retrieval and were excluded and 592/764 (78%) completed all pregnancy assessments. When other factors were controlled speaking a language other than English, having private health insurance and multiple gestation were associated with worse physical health and having private health insurance and better physical health were associated with better mental health. Pregnancy-related hospital admissions were associated with worse physical health and multiple gestation.ConclusionsMaternal age and mode of conception are not associated with pregnancy health and health service use when sociodemographic factors are considered.

Neurofibromatosis type 1 and pregnancy complications: a population-based study

The objective of the study was to determine whether vascular and other complications are more common in pregnant women with neurofibromatosis type 1 (NF1). We performed a population-based retrospective cohort study using the US Nationwide Inpatient Sample, 1988-2009, defining a cohort of pregnancy-related hospitalizations with an associated diagnosis of NF1 and comparing it with the control group not associated with NF1. Multivariable logistic regression was used to adjust for suspected confounders. Among 19 million pregnancy-related admissions between 1988 and 2009, we identified 1553 associated with NF1 (prevalence 0.008%). A diagnosis of NF1 in delivering mothers was associated with gestational hypertension (adjusted odds ratio [AOR], 1.6, 95% confidence interval [CI], 1.2-2.0), preeclampsia (AOR, 2.8, 95% CI, 2.3-3.4), intrauterine growth restriction (AOR, 4.6, 95% CI, 3.7-5.6), cerebrovascular disease (OR, 8.1, 95% CI, 2.6-25.4), preterm labor (AOR, 1.6, 95% CI, 1.4-1.9), and cesarean delivery (AOR, 2.0, 95% CI, 1.8-2.3). Women with NF1 were not significantly more likely to have deep venous thrombosis/pulmonary embolism, acute cardiac events, or stillbirth or to die during their hospitalizations compared with the general obstetric population. NF1 was associated with increased maternal morbidity in pregnancy (including hypertensive and cerebrovascular complications) but not increased maternal mortality. Obstetricians should be aware of the potential for increased antenatal and peripartum complications among women with NF1.

Trends in Pregnancy Hospitalizations That Included a Stroke in the United States From 1994 to 2007

Stroke is an important contributor to maternal morbidity and mortality, but there are no recent data on trends in pregnancy-related hospitalizations that have involved a stroke. This report describes stroke hospitalizations for women in the antenatal, delivery, and postpartum periods from 1994 to 1995 to 2006 to 2007 and analyzes the changes in these hospitalizations over time. Hospital discharge data were obtained from the Nationwide Inpatient Sample, developed as part of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. Pregnancy-related hospitalizations with stroke were identified according to the International Classification of Diseases, Ninth Revision. All statistical analyses accounted for the complex sampling design of the data source. Between 1994 to 1995 and 2006 to 2007, the rate of any stroke (subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, transient ischemic attack, cerebral venous thrombosis, or unspecified) among antenatal hospitalizations increased by 47% (from 0.15 to 0.22 per 1000 deliveries) and among postpartum hospitalizations by 83% (from 0.12 to 0.22 per 1000 deliveries) while remaining unchanged at 0.27 for delivery hospitalizations. In 2006 to 2007, ≈32% and 53% of antenatal and postpartum hospitalizations with stroke, respectively, had concurrent hypertensive disorders or heart disease. Changes in the prevalence of these 2 conditions from 1994 to 1995 to 2006 to 2007 explained almost all of the increase in postpartum hospitalizations with stroke during the same period. Our results have demonstrated an increasing trend in the rate of pregnancy-related hospitalizations with stroke in the United States, especially during the postpartum period, from 1994 to 1995 to 2006 to 2007.

Age and Sex Differences in Hospitalizations Associated with Diabetes

To evaluate national trends in hospitalizations and hospital charges associated with diabetes over a recent 14-year period. We evaluated hospital discharges with a primary or secondary diagnosis of diabetes (250.xx)in the Nationwide Inpatient Sample (1993-2006). Outcomes included population-adjusted estimates of hospital discharges and hospital charges (2006 $U.S.). Overall, discharges associated with diabetes increased 65.3% (1,384/100,000 in 1993, 2,288/100,000 in 2006) over the 14-year period (p < 0.001 test for trend). The largest increase in hospitalizations occurred among adults 30-39 years of age, representing a 102% increase. Among young adults, increases among women were ∼1.3 times greater compared with men, for the 20-29 year (63% vs. 46%) and 30-39 year (118% vs. 85%) age groups, even after excluding pregnancy-related hospitalizations. Overall, women had higher rates of hospitalizations associated with diabetes compared with men, but there was evidence of an age by sex interaction, with higher rates of hospitalizations among women in the younger age groups and among men in the older age groups. Annual inflation-adjusted total charges for hospitalizations with diabetes increased 220% over the period. Large increases in diabetes hospitalizations occurring among adults aged 30-39 years and young women signal a shift in the hospital burden of diabetes.