The effect of hospital acuity on severe maternal morbidity in high-risk patients

Clapp, Mark A.; James, Kaitlyn; Kaimal, Anjali J

doi:10.1016/j.ajog.2018.04.015

Cited by 37 publications

(22 citation statements)

References 19 publications

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“…Under these circumstances, tertiary hospitals with critical maternal care centers should provide educational and consultation functions for lower-level hospitals to a greater extent, even providing training for quality improvement initiatives as specified in the functions of level IV maternal centers in the United States ( 23 ). With the implementation of risk assessment and networks for SMM surveillance ( 49 ), early risk assessment ( 50 , 51 ), and timely transfer to risk-appropriate hospitals ( 52 – 54 ) would play key roles in improving maternal and fetal outcomes. In tertiary hospitals, women who require continuous surveillance but not necessarily intensive care should be shifted to a transitional ward to provide more ICU beds for prenatal intensive care for the most complicated cases (i.e., women with hypertensive diseases of pregnancy and a SOFA score ≥ 2).…”

Section: Discussionmentioning

confidence: 99%

Pregnancy-Related ICU Admissions From 2008 to 2016 in China: A First Multicenter Report

Zhao

Han

Yao

et al. 2018

Critical Care Medicine

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Objectives:To identify the key points for improving severe maternal morbidity by analyzing pregnancy-related ICU admissions in Beijing.Design:This was a retrospective, multicenter cohort study.Setting:Three ICUs in tertiary hospitals in Beijing.Patients:A total of 491 severe maternal cases in any trimester of pregnancy or within 42 days of delivery were reviewed between January 1, 2008, and December 31, 2016.Interventions:None.Measurements and Main Results:Among 491 obstetric ICU admissions (median Sequential Organ Failure Assessment score, 2) out of 87,850 hospital deliveries (a frequency of 5.6 admissions per 1,000 deliveries), the leading diagnoses were postpartum hemorrhage (170; 34.62%), hypertensive disorders of pregnancy (156; 31.77%), and cardio-cerebrovascular diseases (78; 15.9%). Comparing 2008–2011 to 2012–2016, the rates of maternal mortality (2.5% vs 1.9%; p = 0.991) and fetal loss (8.5% vs 8.6%; p = 0.977) did not decrease significantly, whereas the rates of ICU admission (3.05% vs 7.85%; p trends < 0.001) and postpartum hemorrhage (23% vs 38.5%; p = 0.002) increased. Hypertensive disorder (150/156; 96.2% transferred to the ICU postpartum, 24/28 women with fetal loss transferred from lower-level hospitals) was an independent maternal factor associated with fetal loss, and infections were the leading cause of maternal death (6/10) in the ICU.Conclusions:Our study highlights the increasing rate of intensive care admissions for postpartum hemorrhage. Improving prenatal care quality for pregnancy-induced hypertension and sepsis at lower-level hospitals may improve maternal and fetal outcomes. Specifically, providing more effective regional cooperation before transfer and shifting patients who require continuous surveillance but not necessarily intensive care to a transitional ward in a tertiary hospital would provide more ICU beds for more prenatal intensive care for the most complex medical conditions.

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Section: Discussionmentioning

confidence: 99%

Pregnancy-Related ICU Admissions From 2008 to 2016 in China: A First Multicenter Report

Zhao

Han

Yao

et al. 2018

Critical Care Medicine

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“…done at the time of labor [42]. The prevalence of high-risk pregnancies in developed countries differs based on the gestational week and scoring systems used.…”

Section: Plos Onementioning

confidence: 99%

“…The obstetric comorbidity index is used in the United States, but it is applied at the time of labor. A considerable volume of evidence has been gathered from studies in the United States, showing that high-risk pregnancies detected using obstetric comorbidity index scores are associated with high SMM rates [42,[56][57][58]. Three studies conducted in Canada, Denmark, and the United States each used the obstetric comorbidity index retrospectively in huge sample sizes.…”

Section: Plos Onementioning

confidence: 99%

High-risk pregnancies and their association with severe maternal morbidity in Nepal: A prospective cohort study

2020

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Background The early identification of pregnant women at risk of developing complications at birth is fundamental to antenatal care and an important strategy in preventing maternal death. This study aimed to determine the prevalence of high-risk pregnancies and explore the association between risk stratification and severe maternal morbidity. Methods This hospital-based prospective cohort study included 346 pregnant women between 28–32 gestational weeks who were followed up after childbirth at Koshi Hospital in Nepal. The Malaysian antenatal risk stratification approach, which applies four color codes, was used: red and yellow denote high-risk women, while green and white indicate low-risk women based on maternal past and present medical and obstetric risk factors. The World Health Organization criteria were used to identify women with severe maternal morbidity. Multivariate confirmatory logistic regression analysis was performed to adjust for possible confounders (age and mode of birth) and explore the association between risk stratification and severe maternal morbidity. Results The prevalence of high-risk pregnancies was 14.4%. Based on the color-coded risk stratification, 7.5% of the women were categorized red, 6.9% yellow, 72.0% green, and 13.6% white. The women with high-risk pregnancies were 4.2 times more likely to develop severe maternal morbidity conditions during childbirth. Conclusions Although smaller in percentage, the chances of severe maternal morbidity among high-risk pregnancies were higher than those of low-risk pregnancies. This risk scoring approach shows the potential to predict severe maternal morbidity if routine screening is implemented at antenatal care services. Notwithstanding, unpredictable severe maternal morbidity events also occur among low-risk pregnant women, thus all pregnant women require vigilance and quality obstetrics care but high-risk pregnant women require specialized care and referral.

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“…Perhaps the most direct evidence that caring for the sickest women in higher acuity centers is associated with improved outcomes is that women with a high comorbidity index had a significantly higher adjusted relative risk of severe maternal morbidity when they gave birth in hospitals of low acuity (adjusted OR, 9.55; 95% CI, 6.83e13.35) compared with hospitals of high acuity (adjusted OR, 6.50; 95% CI, 5.94e7.09). 20 Additional recent data suggest that hospital delivery volume, health care provider patient volume, and hospital level or rating can all affect maternal outcomes. 20e27 Furthermore, data indicate that outcomes are better if women with certain conditions, such as placenta previa or placenta accreta, are managed in hospitals with high delivery volume.…”

Section: Regionalized Perinatal Carementioning

confidence: 99%

Obstetric Care Consensus #9: Levels of Maternal Care

Kilpatrick¹,

Menard²,

Zahn³

et al. 2019

American Journal of Obstetrics and Gynecology

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The effect of hospital acuity on severe maternal morbidity in high-risk patients

Cited by 37 publications

References 19 publications

Pregnancy-Related ICU Admissions From 2008 to 2016 in China: A First Multicenter Report

Pregnancy-Related ICU Admissions From 2008 to 2016 in China: A First Multicenter Report

High-risk pregnancies and their association with severe maternal morbidity in Nepal: A prospective cohort study

Obstetric Care Consensus #9: Levels of Maternal Care

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