Schwartz/Reisman Emergency Medicine Institute (Varner, Little) and Department of Family and Community Medicine (Varner), University of Toronto; University of Toronto (Varner, Little), Sinai Health System; ICES (Park, Ray); Keenan Research Centre (Ray), Li Ka Shing Knowledge Institute and Department of Obstetrics and Gynecology (Ray), St. Michael's Hospital, Toronto, Ont.
CMAJ Open. 2020 Apr 28;8(2):E304-E312. doi: 10.9778/cmajo.20190154. Print 2020 Apr-Jun.
Peripregnancy emergency department use may be common, but data specific to health care systems like that in Canada are lacking. As prior research was limited to livebirths, omitting pregnancies ending in miscarriage or induced abortion, the current study quantified and characterized emergency department use among women in Ontario with a recognized pregnancy.
This retrospective population-based cohort study included all recognized pregnancies among Ontario residents aged 10-55 years with an estimated date of conception between Apr. 1, 2002, and Mar. 31, 2017. We defined peripregnancy emergency department use as any emergency department visit during pregnancy or within 42 days after pregnancy. We used modified Poisson regression with a robust error variance to generate relative risks (RRs) and 95% confidence intervals (CIs) for the outcome of any peripregnancy emergency department use in association with maternal age, parity, residential income quintile, location of residence, immigrant status, antenatal care provider and number of comorbidities within 120 days before the clinical start of the pregnancy (expressed as total number of Aggregated Diagnosis Groups [ADGs] obtained with the Johns Hopkins Adjusted Clinical Group System). All RRs, except for number of comorbidities, were further adjusted for number of ADGs.
Peripregnancy emergency department use occurred in 1 075 991 (39.4%) of 2 728 236 recognized pregnancies, including 35.8% of livebirths, 47.3% of stillbirths, 73.7% of miscarriages and 84.8% of threatened abortions. A peripregnancy emergency department visit was more likely among women who were less than 25 years of age (adjusted RR 1.16, 95% CI 1.16-1.17), were nulliparous (adjusted RR 1.13, 95% CI 1.13-1.13), resided in the lowest income quintile area (adjusted RR 1.16, 95% CI 1.15-1.16) or in a rural area (adjusted RR 1.50, 95% CI 1.50-1.51), were Canadian-born (adjusted RR 1.22, 95% CI 1.22-1.23), were not seen by an obstetrician (adjusted RR 1.66, 95% CI 1.54-1.80) or had a greater number of ADGs. Emergency department use peaked in the first trimester and in the first week postpartum. Compared to women residing in urban areas, those residing in rural areas had an odds ratio (OR) of 3.44 (95% CI 3.39-3.49) for 3 or more emergency department visits. Women with 3-4 (OR 1.99, 95% CI 1.97-2.01), 5-6 (OR 3.55, 95% CI 3.49-3.61), or 7 or more (OR 7.59, 95% CI 7.39-7.78) prepregnancy comorbidities were more likely to have 3 or more peripregnancy emergency department visits than were those with 2 or fewer comorbidities.
Peripregnancy emergency department use occurred in nearly 40% of pregnancies, notably in the first trimester and early in the postpartum period. Efforts are needed to streamline rapid access to ambulatory obstetric care during these peak periods, when women are susceptible to miscarriage or a complication after a livebirth.
围孕期急诊就诊可能较为常见，但加拿大等医疗体系的数据却十分缺乏。由于之前的研究仅限于活产，不包括流产或人工流产终止的妊娠，因此本研究量化并描述了安大略省有明确妊娠的女性的急诊就诊情况。
本回顾性基于人群的队列研究纳入了安大略省年龄在 10-55 岁之间、预计受孕日期在 2002 年 4 月 1 日至 2017 年 3 月 31 日之间的所有妊娠居民。我们将围孕期急诊就诊定义为妊娠期间或妊娠后 42 天内的任何急诊就诊。我们使用改良泊松回归模型和稳健误差方差来计算围孕期急诊就诊的相对风险（RR）和 95%置信区间（CI），与母亲年龄、产次、居住收入五分位数、居住地点、移民身份、产前保健提供者和妊娠临床起始前 120 天内的合并症数量（用约翰霍普金斯调整临床分组系统获得的总 Aggregated Diagnosis Groups [ADG] 数表示）有关。除了合并症数量外，所有 RR 都进一步根据 ADG 数量进行了调整。
在 2 728 236 例确诊妊娠中，有 1 075 991 例（39.4%）发生了围孕期急诊就诊，其中包括 35.8%的活产、47.3%的死产、73.7%的流产和 84.8%的先兆流产。与年龄小于 25 岁的女性（调整 RR 1.16，95%CI 1.16-1.17）、初产妇（调整 RR 1.13，95%CI 1.13-1.13）、居住在收入最低五分位数地区（调整 RR 1.16，95%CI 1.15-1.16）或农村地区（调整 RR 1.50，95%CI 1.50-1.51）、加拿大出生（调整 RR 1.22，95%CI 1.22-1.23）、未接受产科医生诊治（调整 RR 1.66，95%CI 1.54-1.80）或合并症数量较多的女性相比，围孕期急诊就诊的可能性更高。急诊就诊高峰出现在妊娠早期和产后第一周。与居住在城市地区的女性相比，居住在农村地区的女性有 3 次或以上急诊就诊的优势比（OR）为 3.44（95%CI 3.39-3.49）。有 3-4 种（OR 1.99，95%CI 1.97-2.01）、5-6 种（OR 3.55，95%CI 3.49-3.61）或 7 种或以上（OR 7.59，95%CI 7.39-7.78）孕前合并症的女性更有可能有 3 次或以上的围孕期急诊就诊。
围孕期急诊就诊发生率接近 40%，尤其是在妊娠早期和产后早期。在这些高峰期，当女性容易发生流产或活产后并发症时，需要努力简化门诊产科护理的快速通道。
