Emergency Department Care in the Postpartum Period

Batra, Priya; Fridman, Moshe; Leng, Mei; Gregory, Kimberly D.

doi:10.1097/aog.0000000000002269

Cited by 40 publications

(38 citation statements)

References 22 publications

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“…9,11,13 We also describe the incidence of unexpected office visits and emergency room visits, this last one being higher than previously reported after CD. 3 The etiologies associated with these outcomes are consistent with prior reports after CD, with the most common being infectious and hypertensive disorders. 14,15 Our study found that the vast majority were associated with infectious etiologies, while previous studies have reported lower infectious reason-for-visit percentages.…”

Section: Discussionsupporting

confidence: 87%

“…A recent study showed that 8.3% of the patients who delivered in California visited the emergency department at least once during the first 3 months postpartum. 3 Almost one-third of women in the United States delivers via cesarean delivery (CD). 4 Compared with vaginal delivery, women undergoing a CD have a 5-to 10-fold increased risk of complications related to infections, 5 such as endometritis, wound complications, including disruption and infection.…”

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confidence: 99%

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Incidence and Risk Factors for Hospital Readmission or Unexpected Visits in Women Undergoing Unscheduled Cesarean Delivery

et al. 2019

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Objective Hospital readmissions are increasingly tracked and assessed for value-based compensation. Our objective was to determine the incidence and risk factors associated with post-cesarean delivery (CD) readmissions or unexpected visits, defined as unexpected office or emergency room visits. Study Design This is a secondary analysis of a multicenter randomized controlled trial of adjunctive azithromycin prophylaxis for CD performed in laboring patients with viable pregnancies. Patients were followed up to 6 weeks postpartum. Our primary outcome was a composite of hospital readmission or unexpected visit, defined as unscheduled clinic or emergency department visits. Data of hospital readmissions, unexpected visits, and their reasons were collected. Demographics, antepartum, intrapartum, and postpartum risk factors were evaluated in bivariate analyses and multivariable logistic regression modeling. Results A total of 1,019 women were randomized to azithromycin and 994 to placebo. The prevalence of readmission or unexpected visit was 10.2% (95% confidence interval [CI]: 8.9–11.6), with rates of 3.8% (95% CI: 3.0–4.7%) hospital readmissions, 6.9% (95% CI: 5.8–8.0%) emergency room visits, and 4.2% (95% CI: 3.4–5.2%) unexpected clinic visits. The most common causes were infectious disease and hypertensive disorder. Women with readmissions or unexpected visits were more likely to be obese and diabetic, as well as experience longer length of ruptured membranes, intrauterine pressure catheter placement, and postpartum fevers. On multivariable analysis, diabetes (adjusted odds ratio [aOR]: 1.6, 95% CI: 1.1–2.4), prolonged ruptured membranes (aOR: 1.9, 95% CI: 1.3–2.8), and postpartum fevers (aOR: 4.6, 95% CI: 3.0–7.0) were significantly positively associated with readmission or unscheduled visit, while azithromycin was a protective (aOR: 0.6, 95% CI: 0.5–0.9). Conclusion Women who had postpartum fever were at especially high risk for readmission or unexpected visits. Diabetes, prolonged ruptured membranes, and postpartum fevers were significantly associated with the adverse outcome, and azithromycin was associated with lower rates of readmission and unexpected visits.

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Section: Discussionsupporting

confidence: 87%

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confidence: 99%

Incidence and Risk Factors for Hospital Readmission or Unexpected Visits in Women Undergoing Unscheduled Cesarean Delivery

et al. 2019

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“…Total 5 to 12% of women have a hospital emergency room encounter within the initial 6-week postpartum period. [4][5][6][7] Based solely on discharge coding data, risk factors for emergency room visits include primiparity, young age, antepartum and delivery-related complications, hypertensive disorders of pregnancy, and cesarean delivery. 7,8 Women presenting to the emergency room most frequently complain of wound complications, fever, abdominal pain, and hypertension.…”

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confidence: 99%

A Gap in Care? Postpartum Women Presenting to the Emergency Room and Getting Readmitted

et al. 2020

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Objective Emergent postpartum hospital encounters in the first 42 days after birth are estimated to complicate 5 to 12% of births. Approximately 2% of these visits result in admission. Data on emergent visits and admissions are critically needed to address the current maternal morbidity crisis. Our objective is to characterize trends in emergent postpartum hospital encounters and readmissions through chief complaints and admission diagnoses over a 4.5-year period. Study Design All postpartum hospital encounters within 42 days of delivery at our institution from 2015 to 2019 were included. We reviewed demographic information, antepartum, intrapartum, and postpartum care and postpartum hospital encounters. Trends in hospital presentation and admission over the study period were analyzed. Comparisons between women who were admitted to those managed outpatient were performed. Statistical analysis included Chi-square, student's t-test, and Mantel–Haenszel test for trend and ANOVA, as appropriate. A p-value <0.05 considered significant. Results Among 8,589 deliveries, 491 (5.7%) presented emergently to the hospital within 42 days of delivery, resulting in 576 hospital encounters. From 2015 to 2019, annual rates of presentation were stable, ranging from 5.0 to 6.4% (p = 0.09). Of the 576 hospital encounters, 224 (38.9%) resulted in an admission with increasing rates from 2.0% in 2015 to 3.4% in 2019 (p = 0.005). Primiparous women with higher body mass index, cesarean delivery, and blood loss ≥1, 000 mL during delivery were significantly more likely to be admitted to the hospital. Women with psychiatric illnesses increasingly utilized the emergency room in the postpartum period (6.7–17.2%, p = 0.03). The most common presenting complaints were fever, abdominal pain, headache, vaginal bleeding, wound concerns, and high blood pressure. Admitting diagnoses were predominantly hypertensive disorder (22.9%), wound complications (12.8%), endometritis (9.6%), headache (6.9%), and delayed postpartum hemorrhage (5.6%). Conclusion The average proportion of women presenting for an emergent hospital encounter in the immediate 42-day postpartum period is 5.7%. Nearly 40% of emergent hospital encounters resulted in admission and the rate increased from to 2.0 to 3.4% over the study period. The most common reasons for presentation were fever, abdominal pain, headache, vaginal bleeding, wound concerns, and hypertension. Hypertension, wound complications, and endometritis accounted for the top three admission diagnoses.

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“…However, it is known that women who underwent cesarean delivery frequently present to the ED postpartum. 6,8 It remains unclear if the ESI is useful for women who underwent vaginal delivery. Second, although our hospital protocol is for postpartum women to be evaluated in the ED instead of on the Labor and Delivery unit, 60 women were directly transferred to the labor and delivery unit or an inpatient floor either from the physician's office or from another hospitals.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

“…[3][4][5] Between 5 and 25% of postpartum women present to the ED at least one time after delivery. [6][7][8] Common causes of postpartum ED visits include urinary tract infection, hypertensive disorders, surgical site infections, and abdominal pain. [6][7][8] Although hypertensive disorders are the second most common indications for postpartum readmission, 6,8,9 blood pressure-a key vital sign-is not included in the ESI version 4 algorithm (►Fig.…”

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confidence: 99%

Evaluation of the Emergency Severity Index (Version 4) in Postpartum Women after Cesarean Delivery

2020

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Objective The Emergency Severity Index (ESI) version 4 is a 5-level triage system (1 being the highest acuity and 5 being the lowest acuity) used in the emergency department (ED). Our goal of the study was to compare rates of readmission according to ESI in postpartum women. Study Design This was a secondary analysis of a retrospective cohort study of all women who presented to the ED within 6 weeks after cesarean delivery. The acuity level was assigned by triage nurses at the time of triage presentation. Our primary outcome was postpartum readmission. To examine if the addition of blood pressure to vital sign abnormalities would improve the prediction for readmission, we created a modified ESI. We identified women who had an ESI of level 3 and reassigned to a modified ESI of level 2 if blood pressure was in the severe range. Receiver operating characteristic curves with area under the curve (AUC) were created and compared between ESI and modified ESI. Results Of 439 women, ESI distribution was 0.2% ESI 1, 23.7% ESI 2, 56.0% ESI 3, 19.4% ESI 4, and 0.7% ESI 5. Readmission rates by ESI level were 100% ESI 1, 47% ESI 2, 18% ESI 3, 2% ESI 4, and 0% ESI 5 (p < 0.001). Of 246 women who were assigned an ESI of 3, total 25 had severe range blood pressures and were reassigned to a modified ESI of 2. Of these 25 women, 14 were readmitted. The AUC of the modified ESI was statistically higher than that of the standard ESI (AUC: 0.77 and 95% confidence interval: 0.72–0.82 vs. AUC: 0.73 and 95% confidence interval: 0.68–0.78; p < 0.01) Conclusion The ESI was a useful tool to identify women who required postpartum readmission. Incorporation of severe range blood pressure as a parameter of acuity improved the prediction of readmission. Key Points

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Emergency Department Care in the Postpartum Period

Abstract: One in 12 California women visited the emergency department in the first 90 days after postpartum discharge. Women at increased risk for postpartum emergency department use per our validated model (eg, low income, birth complications) may benefit from earlier scheduled postpartum visits.

Cited by 40 publications

References 22 publications

Incidence and Risk Factors for Hospital Readmission or Unexpected Visits in Women Undergoing Unscheduled Cesarean Delivery

Incidence and Risk Factors for Hospital Readmission or Unexpected Visits in Women Undergoing Unscheduled Cesarean Delivery

A Gap in Care? Postpartum Women Presenting to the Emergency Room and Getting Readmitted

Evaluation of the Emergency Severity Index (Version 4) in Postpartum Women after Cesarean Delivery

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