Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY.
Department of Neurological Surgery, Keck School of Medicine, Los Angeles, CA.
Am J Obstet Gynecol. 2018 Oct;219(4):401.e1-401.e14. doi: 10.1016/j.ajog.2018.07.001. Epub 2018 Jul 11.
There are limited data on when postpartum readmissions for thromboembolism occur after delivery hospitalizations on a population basis in the United States.
We sought to characterize risk factors for and timing of postpartum venous thromboembolism readmission after delivery hospitalization discharge.
The Healthcare Cost and Utilization Project Nationwide Readmissions Database for calendar years 2013 and 2014 was used to perform a retrospective cohort study evaluating risk for readmission for venous thromboembolism within 60 days of discharge from a delivery hospitalization. Risks for deep vein thrombosis and pulmonary embolism were individually assessed. Obstetric, medical, demographic, and hospital factors associated with postpartum readmission for venous thromboembolism were analyzed. Risk was characterized as odds ratios with 95% confidence intervals. Both unadjusted and adjusted analyses were performed. Adjusted analyses included relevant obstetric, medical, demographic, and hospital factors within logistic regression models.
From Jan. 1 through Oct. 31 in 2013 and 2014, 6,269,641 delivery hospitalizations were included in the analysis. In all, 2975 cases of readmission for any venous thromboembolism were identified (4.7 per 10,000 delivery hospitalizations) including 1170 cases of deep vein thrombosis and 1805 cases of pulmonary embolism. In all, 69.6% of readmissions for any venous thromboembolism occurred within the first 20 days of discharge vs 22.3% and 8.0% at 21-40 and 41-60 days after discharge. Median times to readmission were 12.7, 14.0, and 11.7 days for venous thromboembolism, deep vein thrombosis, and pulmonary embolism, respectively. Women readmitted for any venous thromboembolism were more likely to have a history of venous thromboembolism (4.2% vs 0.3%, P < .01), to have had a cesarean delivery (54.4% vs 32.4%, P < .01), to have a thrombophilia (1.8% vs 0.4%, P < .01), to have had a longer delivery hospitalization of >3 days for vaginal delivery and >4 days for cesarean (18.0% vs 6.6%, P < .01), to have been diagnosed with gestational hypertension or preeclampsia (19.7% vs 8.2%, P < .01), and to have had postpartum hemorrhage with transfusion (2.6% vs 0.5%, P < .01). These factors retained significance in adjusted models. History of venous thromboembolism and hemorrhage with transfusion were associated with the largest odds of readmission (odds ratio, 9.5; 95% confidence interval, 6.6-13.6, and odds ratio, 3.6; 95% confidence interval, 2.4-5.5, respectively). Other factors associated with increased odds included thrombophilia (odds ratio, 2.0; 95% confidence interval, 1.2-3.5), cesarean delivery (odds ratio, 2.0; 95% confidence interval, 1.8-2.3), longer delivery hospitalization (odds ratio, 1.8; 95% confidence interval, 1.5-2.2), and preeclampsia or gestational hypertension (odds ratio, 2.0; 95% confidence interval, 1.6-2.4).
While the majority of events occurred within 20 days of discharge, risk factors other than thrombophilia and prior venous thromboembolism were generally associated with modestly increased odds of events, and only a small proportion of readmissions occurred among women with thrombophilia and prior events. Our data demonstrate both the challenging nature and urgent need for further research to determine which clinical practices and interventions may reduce risk for venous thromboembolism readmissions on a population basis.
在美国，基于人群的基础上，关于产后血栓栓塞症在分娩住院后何时再次住院的数据有限。
我们旨在描述产后静脉血栓栓塞症再入院的风险因素和时间。
利用 2013 年和 2014 年的医疗保健成本和利用项目全国再入院数据库，进行回顾性队列研究，评估分娩后出院后 60 天内静脉血栓栓塞症再入院的风险。分别评估深静脉血栓形成和肺栓塞的风险。分析与产后静脉血栓栓塞症再入院相关的产科、医学、人口统计学和医院因素。风险特征为 95%置信区间的优势比。进行了未调整和调整分析。调整分析包括逻辑回归模型中相关的产科、医学、人口统计学和医院因素。
2013 年 1 月 1 日至 2014 年 10 月 31 日期间，共纳入 6269641 例分娩住院患者。共有 2975 例静脉血栓栓塞症再入院病例（每 10000 例分娩住院 4.7 例），包括 1170 例深静脉血栓形成和 1805 例肺栓塞。所有静脉血栓栓塞症再入院的 69.6%发生在出院后 20 天内，22.3%和 8.0%分别发生在出院后 21-40 天和 41-60 天。静脉血栓栓塞症、深静脉血栓形成和肺栓塞的中位再入院时间分别为 12.7、14.0 和 11.7 天。任何静脉血栓栓塞症再入院的妇女更有可能有静脉血栓栓塞症病史（4.2%比 0.3%，P <.01）、剖宫产（54.4%比 32.4%，P <.01）、血栓形成倾向（1.8%比 0.4%，P <.01）、阴道分娩住院时间>3 天和剖宫产>4 天（18.0%比 6.6%，P <.01）、妊娠高血压或子痫前期诊断（19.7%比 8.2%，P <.01）和产后出血伴输血（2.6%比 0.5%，P <.01）。这些因素在调整模型中仍具有重要意义。静脉血栓栓塞症和出血伴输血病史与再入院的最大优势比相关（优势比，9.5；95%置信区间，6.6-13.6，和优势比，3.6；95%置信区间，2.4-5.5）。其他与增加优势相关的因素包括血栓形成倾向（优势比，2.0；95%置信区间，1.2-3.5）、剖宫产（优势比，2.0；95%置信区间，1.8-2.3）、分娩住院时间延长（优势比，1.8；95%置信区间，1.5-2.2）和子痫前期或妊娠高血压（优势比，2.0；95%置信区间，1.6-2.4）。
虽然大多数事件发生在出院后 20 天内，但除血栓形成倾向和既往静脉血栓栓塞症外，其他风险因素通常与事件发生的优势比略有增加，只有一小部分再入院发生在有血栓形成倾向和既往事件的妇女中。我们的数据表明，需要进一步研究以确定哪些临床实践和干预措施可能会降低人群静脉血栓栓塞症再入院的风险，这是一项具有挑战性且紧迫的任务。
