Objective
The purpose of this study was to define patterns of morbidity that are experienced by women in the postpartum period who seek care in the emergency department within 42 and 100 days of discharge.
Study Design
We conducted a retrospective examination of discharge diagnosis codes and descriptions for emergency department visits and analyzed temporal patterns of both emergency department visits and hospital readmissions.
Results
During 2007, 222,084 patients delivered in Hospital Corporation of America facilities in the United States. Among these women, there were 10,751 emergency department visits within 42 days of delivery (4.8%). Fifty-eight percent of the patients were seen for conditions that were related to pregnancy; 42% of the patients were seen for conditions unrelated to pregnancy. Fifty percent of patients in the postpartum period who were seen either in the emergency department (21,833 patients) or readmitted (5190 patients) during both 2007 and 2008 had this encounter within 10 days of discharge.
Conclusion
The scheduling and content of traditional postpartum education and clinical visits appear poorly suited to the prevention of puerperal morbidity.
Four million women give birth annually in the United States. Most typically are scheduled for a single office visit 6 weeks later. The timing of this visit is based on the traditional definition of the puerperium, and the content of this visit to a great extent focuses on the provision of contraception. However, this definition of the puerperium is largely arbitrary; most of the hemodynamic changes that are associated with pregnancy have resolved by postpartum week 2, whereas changes in breast physiology may persist long beyond 6 weeks, particularly in women who breastfeed. Further, no evidence exists to support the efficacy of this approach to care in reducing puerperal morbidity. Although the initiation of contraception with the diaphragm or intrauterine device may be facilitated by a visit at postpartum week 6 because of the resolution of pregnancy-induced physiologic changes in the uterus and lower genital tract by this time, these methods of contraception currently are chosen by <3% of women in the United States.
Little information exists regarding clinical illness in the puerperium after hospital discharge or of emergency department use in this patient population. Such data would be of importance in the facilitation of focused attempts to reduce maternal morbidity. In addition, the economic implications of emergency department use in the 4 million women who deliver babies annually in the United States are considerable, particularly in light of recent Federal government proposals to bundle hospital payments to include care from certain providers for the 30 days after discharge. Accordingly, we sought to investigate both the nature and temporal patterns of postdischarge puerperal illness using emergency department visits and hospital readmissions as arbiters of potentially significant postpartum morbidity.
Methods
The Hospital Corporation of America is the largest inpatient health care delivery system in the United States, with approximately 220,000 annual deliveries in 21 states. Previous publications have suggested that the demographic and geographic diversity of this hospital group make it representative of the nation as a whole. This study had 2 parts. First, we examined diagnostic coding for all women who were seen and discharged from the emergency department within 42 days of hospital discharge after delivery during 2007 in all system hospitals. Patients were stratified according to diagnostic code groupings that involved similar pathophysiologic conditions. Most patients had >1 discharge code. In such cases, the primary diagnosis was used in the analysis, unless a secondary diagnosis was judged to be more specific or to represent the principle underlying clinical problem. Examples would include a primary diagnosis of abdominal pain, right upper quadrant (78901) with a secondary diagnosis of cholecystitis (57420) or a primary diagnosis of altered mental status (78097) and a secondary diagnosis of cerebral thrombosis with infarct (43401). In these and similar cases, patients were analyzed according to the more specific secondary diagnosis. Patients were also stratified according to the mode of delivery (vaginal vs cesarean).
In a second analysis, we examined the temporal pattern of both emergency department visits with discharge home and of inpatient hospital readmissions from either the emergency department or another location for 100 days after the initial delivery discharge for all of the roughly one-half million women who delivered during 2007 and 2008.
This was a quality improvement project that used deidentified data for analysis.
However, institutional review board approval for publication of these data was obtained.
Statistical analysis was with the chi-square test using the Yates continuity correction.
Results
During 2007, 222,084 women delivered in domestic facilities of the Hospital Corporation of America. This included 140,377 vaginal births and 81,707 cesarean births. This cohort of women accounted for 10,751 emergency department visits in the delivering facility or an allied facility within 42 days of discharge. This included 5673 visits among women who delivered vaginally (4.0%) and 5078 visits among women who had a cesarean delivery (6.2%). Some women were evaluated in the emergency department on >1 occasion, many for unrelated conditions. Thus, although the ratio of visits to deliveries is 4.8%, only 4.2% of individual women were seen ≥1 times in the emergency department. However, because the avoidance of the morbidity and cost that is associated with 2 visits to the emergency department is of similar concern, whether this involved 1 woman twice or 2 women once, the analyses of morbidity categories in Tables 1-3 and Figures 1 and 2 are based on distinct encounters.
| Condition | Patients presenting after vaginal birth per 1000, n (%) | Patients presenting after cesarean birth per 1000, n (%) | Total patients presenting with condition, n | Postpartum women with condition per 1000 births, % | P value | Odds ratio, CI |
|---|---|---|---|---|---|---|
| Urinary tract infection | 521 (3.7) | 344 (4.2) | 865 | 6.2 | .074 | 0.990–1.301 |
| Abdominal pain, unspecified further | 265 (1.9) | 404 (5.0) | 669 | 4.8 | .000 | 1.173–1.522 |
| Hypertension/Preeclampsia related | 193 (1.4) | 225 (2.3) | 418 | 3.0 | .000 | 1.655–2.431 |
| Endometritis | 217 (1.6) | 187 (2.3) | 404 | 2.9 | .000 | 1.219–1.801 |
| Mastitis | 279 (2.0) | 118 (1.4) | 397 | 2.8 | .004 | 0.586–0.900 |
| Facial or extremity edema without hypertension | 91 (0.7) | 123 (1.5) | 214 | 1.5 | .000 | 1.774–3.046 |
| Dressing change/suture removal | 54 (0.4) | 128 (1.6) | 182 | 1.3 | .000 | 2.970–5.597 |
| Constipation | 84 (0.6) | 80 (1.0) | 164 | 1.2 | .002 | 1.206–2.221 |
| Fever, unspecified further | 78 (0.5) | 80 (1.0) | 158 | 1.1 | .000 | 1.292–2.405 |
| Breast engorgement | 96 (0.7) | 48 (0.6) | 144 | 1.0 | .439 | 0.608–1.213 |
| Noninflammatory disease, vagina | 73 (0.5) | 56 (0.7) | 129 | 0.6 | .142 | 0.932–1.864 |
| Trunk cellulitis | 20 (0.1) | 92 (1.1) | 112 | 0.5 | .000 | 4.900–12.772 |
| Hemorrhoids | 52 (0.4) | 30 (0.4) | 82 | 0.4 | 1.000 | 0.635–1.548 |
| Episiotomy infection/breakdown | 58 (0.4) | 3 (<0.1) | 61 | 0.3 | .000 | 0.029–0.268 |
| Bell’s palsy/facial weakness | 38 (0.3) | 13 (0.2) | 51 | 0.3 | .126 | 0.316–1.092 |
| Other anesthetic complications | 27 (0.2) | 20 (0.3) | 47 | 0.3 | .504 | 0.719–2.252 |
| Condition | Patients after vaginal birth per 1000, n (%) | Patients after cesarean birth per 100, n (%) | Total patients with condition, n | Postpartum women with condition per 1000 births, % | P value | Odds ratio, CI |
|---|---|---|---|---|---|---|
| Postpartum hemorrhage | 474 (3.4) | 189 (2.3) | 663 | 3.0 | .000 | 0.578–0.810 |
| Wound infection/disruption | 0 | 482 (5.9) | 482 | 2.2 | .000 | 216.849–∞ |
| Other surgical complications | 7 (<0.1) | 253 (5.0) | 260 | 1.2 | .000 | 29.884–129.818 |
| Lumbar puncture headache | 173 (1.2) | 80 (1.0) | 253 | 1.1 | .101 | 0.610–1.035 |
| Psychiatric condition or drug abuse | 157 (1.1) | 95 (1.2) | 252 | 1.1 | .815 | 0.806–1.341 |
| Thrombophlebitis | 48 (0.3) | 21 (0.3) | 69 | 0.3 | .332 | 0.452–1.248 |
| Heart failure/pulmonary edema/fluid overload | 4 (<0.1) | 23 (0.3) | 27 | 0.1 | .000 | 3.573–27.331 |
| Eclampsia | 1 (<0.1) | 4 (<0.1) | 5 | <0.1 | .124 | 1.033–45.713 |
| Intracranial hemorrhage | 3 (<0.1) | 0 | 3 | <0.1 | .470 | 0.000–2.200 |
| T otal | 867 (6.2) | 1147 (14.0) | 2014 | 9.1 | .000 | 2.097–2.503 |
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