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Obstetric and Non-Obstetric Indications for Admission in the Ante
Journal of Women's Health Care

Journal of Women's Health Care
Open Access

ISSN: 2167-0420

+44-7360-538437

Research Article - (2012) Volume 1, Issue 1

Obstetric and Non-Obstetric Indications for Admission in the Antepartum and Postpartum Periods of Pregnancy

Thaddeus P. Waters* and Jennifer L. Bailit
Metrohealth Medical Center, Department of Obstetrics and Gynecology, Cleveland, OH, 44109, USA
*Corresponding Author: Thaddeus P. Waters, Metrohealth Medical Center, Department of Obstetrics and Gynecology, Cleveland, OH, 44109, USA, Tel: 216-778-8446, Fax: 216-778-8847 Email:

Abstract

Objective: To determine the most common non-obstetric indications for admission during the antepartum and postpartum period of pregnancy.

Methods: This is a population-based investigation of the primary diagnoses for admission in the antepartum and postpartum periods of pregnancy. Data was obtained from the Healthcare Cost and Utilization Project’s State Inpatient Database for the state of California for 2005. The frequency of each primary diagnosis was determined. Diagnoses were classified as obstetric or non-obstetric and compared for differences in maternal race, age and insurance provider.

Results: 576,846 total maternal admissions were identified with 35,158 antepartum (6.1%), 536,415 intrapartum (93.0%) and 5273 postpartum (0.9%). Overall, 26.6% of admissions were non-obstetric in nature. The most common non-obstetric indication for antenatal admission was urinary tract infections. The most common postpartum non-obstetric indication for admission was psychiatric/substance abuse disorders.

Conclusions: Many admissions during pregnancy are non-obstetric in nature and may be amenable to outpatient screening.

Keywords: Antepartum; Postpartum; Hospitalizations

Background

While most women are healthy during pregnancy, many women will require hospitalization. According to data published from managed care organizations, a significant portion (8-27%) of pregnant women will be hospitalized at least once during pregnancy for a condition other than delivery [1,2]. The majority of these women will be discharged from the hospital prior to labor. These admissions potentially account for a substantial use of health care resources.

Previous investigations [3-5] have provided estimates of pregnancy associated hospitalizations, with the most recent data based upon 1999-2000 maternal admissions [2]. This publication concluded that pregnancy-associated hospitalizations appeared to be on the decline [4]. Accurate estimates of maternal medical conditions complicating pregnancy are essential to determine optimal strategies and approaches to patient care [6]. While previous investigations have provided data regarding pregnancy-associated admissions, scant information has been published evaluating the antepartum and postpartum periods of pregnancy separately. The postpartum period of pregnancy has long been recognized as a distinct period of pregnancy with significant hormonal and physiologic changes that pose unique risks. However the majority of maternal admission data and reported associated maternal morbidity during pregnancy has focused on admissions that occur either prior to or for delivery. Investigations which have previously attempted to assess postpartum morbidity have focused on either the immediate complications that occur prior to discharge or morbidity associate with a particular mode of delivery. In order to develop potential strategies to prevent admission, or postpartum readmission, accurate data regarding the indications for admission are essential. Therefore, the purpose of this investigation was to provide current data regarding pregnancy-associated hospitalizations and to evaluate the antepartum and postpartum periods of pregnancy for indications for admission. Additionally, we sought to determine the most common obstetric and non-obstetric indications for admission in the antepartum and postpartum periods of pregnancy and evaluate the relative proportion of hospital charges attributable to each condition.

Materials And Methods

This is a population-based study of the primary diagnoses for admission in the antepartum and postpartum periods of pregnancy. All data was obtained from hospital discharge data from the Healthcare Cost and Utilization Project’s (HCUP) State Inpatient Database (SID) for California. The HCUP is a federal/state/industry partnership sponsored by the Agency for Healthcare Research and Quality (AHRQ) to build a multi-state health care data system, with data obtained from state governments and state hospital associations. The SID contains comprehensive inpatient discharge abstracts from participating hospitals and encompasses approximately 90 percent of all community hospital discharges in participating States. For each discharge, it includes International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, length of stay, total hospital charges and patient demographic information. The AHRQ secures the data from each state wide data organization and transforms each data set into a common format [7]. For this investigation, we choose to use the California State Inpatient Database for 2005 given the population size and diverse demographics of the state. From 2005 California hospital discharges, we identified all admission during pregnancy or the postpartum. Maternal admissions were stratified into three groups based on the patient’s primary diagnosis and timing of delivery. For this investigation, only the primary admitting diagnosis was used for evaluation as secondary diagnosis codes may not accurately reflect the reason for admission. To estimate the timing of pregnancy when the admission occurred, we assigned patients in the following manor: antepartum (admitted during pregnancy but not delivered during the same admission), intrapartum (admitted and delivered during the same admission) and postpartum (admitted after delivery). Only antepartum and postpartum admissions were included in this investigation. Primary discharge diagnoses were placed into 55 mutually exclusive categories. Diagnoses were then grouped by obstetric or non-obstetric related conditions. Table 1 presents the complete list of ICD-9 groupings variables and if diagnosis was considered obstetric or non-obstetric. The designation of a primary discharge diagnosis variable as obstetric or non-obstetric did not change for antepartum or postpartum admissions except for anemia and diabetes mellitus. Antepartum anemia was considered a non-obstetric condition, but was categorized as an obstetric complication postpartum. Diabetes mellitus was labeled as an obstetric condition in the antepartum period, but non-obstetric in the postpartum. Analyses of antepartum and postpartum admissions were performed separately. The frequencies of each category, as well as the most common obstetric and non-obstetric indications for admission were determined. Additionally, the percent of each category by maternal age, race and insurance provider were calculated. Finally, total charges for all admissions were determined and the percent contribution of each diagnosis to all admissions and to obstetric or non-obstetric admissions was determined. Statistical analyses were performed using STATA version 8.2 (College Station, TX). Chi-square and t-test were performed where appropriate. A p-value <0.05 was considered significant. This project had the approval of the Metro Health Medical Center Institutional Review Board.

Results

We identified 576,846 maternal admissions in our data set. The distribution of admissions was as follows: 35,158 antepartum (6.1%), 536,415 intrapartum (93.0%) and 5273 postpartum (0.9%). Table 1 presents the 55 categories of primary diagnoses, the grouping variables used for all primary diagnoses, if a diagnosis was considered obstetric or non-obstetric in nature and the frequency of each diagnosis for the entire sample size. Overall, the most common obstetric indication for admission was preterm labor (22.4%) and the most common non-obstetric indication for admission was urinary tract infections (13.2%). Of 35,158 antepartum admissions, 26.7% (n=9,275) were for non-obstetrical indications. Total antepartum hospital charges were 524.8 million dollars with 36.9% (193.8 million dollars) for non-obstetrical indications. Table 2 presents the maternal characteristics of the antepartum admissions and the percent of admissions which occurred on a weekend sorted by obstetric and non-obstetric hospitalizations. In general, obstetric admissions were older, more often Caucasian, with a lower frequency of weekend admissions compared to non-obstetric hospitalizations. The distribution of all antepartum diagnoses along with the percent of total antepartum charges attributable to each diagnosis are presented in Table 3. Preterm labor was the most common condition requiring hospitalization (25.8%). However, urinary tract infections were the most-common non-obstetrical indication for admission and were the largest contributor to total (both obstetric and non-obstetric) antepartum hospital charges (22.4%). The frequency of the most common primary diagnoses sorted by obstetrical and nonobstetrical indications for admission are presented in Figures 1 and 2 respectively. We have also included the relative percent contribution of each diagnosis to all antepartum obstetric or non-obstetric charges.

womens-health-care-antepartum-obstetric

Figure 1: Distribution of most common antepartum obstetric indications for admission with associated charges.

womens-health-care-associated-charges

Figure 2: Distribution of most common antepartum non-obstetric indications for admission with associated charges.

Categories of Primary Diagnoses Variable Obstetric or Non-obstetric Total
N=40431
% All admissions
Preterm labor Preterm labor* Obstetric 9060 22.4
Pregnancy NOS Pregnancy NOS Obstetric 7401 18.3
Urinary tract infection Pyelonephritis (58) Non-obstetric 5334 13.2
  Cystitis (n=5276)      
Hyperemesis Hyperemesis* Obstetric 2847 7.0
Vaginal bleeding Vaginal bleeding Obstetric 2541 6.3
Hypertension Hypertension Obstetric 2039 5.0
Diabetes mellitus Diabetes mellitus Obstetric*+ 1483 3.7
Psychiatric/substance abuse Substance abuse (n=91) Non-obstetric 1251 3.1
  Psychiatric (n=1160)      
Endometritis Endometritis+ Obstetric 844 2.1
Infection NOS Infection NOS Non-obstetric 835 2.1
Wound infection Wound infection+ Obstetric 678 1.7
Incompetent cervix Incompetent cervix* Obstetric 700 1.7
Gynecology Fibroids (n=98) Non-obstetric 644 1.6
  Ovarian mass/torsion (n=43)      
  Gynecologic anomaly (n=450)      
  Gynecology NOS (n=53)      
PROM PROM* Obstetric 628 1.6
Fetal indications Fetal indications* Obstetric 584 1.4
Cardiac Congestive heart failure (n=123) Non-obstetric 389 1.0
  Myocardial infarction (n=3)      
  Cardiac NOS (n=263)      
Chronic renal disease Chronic renal disease Non-obstetric 358 0.9
Injury Injury Non-obstetric 314 0.8
PE/DVT Pulmonary embolism (n=92) Non-obstetric 278 0.7
  Deep venous thrombosis (n=186)      
Anemia Anemia Non-obstetric** 286 0.7
Mastitis Mastitis+ Obstetric 243 0.6
Abdominal pain/back pain Abdominal pain (n=97) Non-obstetric 148 0.4
  Back pain (n=51)      
Pulmonary Asthma (n=29) Non-obstetric 161 0.4
  Pulmonary NOS (n=132)      
Neurology Neurology NOS Non-obstetric 163 0.4
Multifetal preganncy Multifetal pregnancy* Obstetric 162 0.4
Appendicitis Appendicitis Non-obstetric 119 0.3
GI Gastroenteritis (n=43) Non-obstetric 104 0.3
  GI NOS (n=61)      
Postdates Postdates* Obstetric 114 0.3
Gallbladder/pancreas Gallbladder (n=91) Non-obstetric 136 0.3
  Pancreas (n=45)      
Other medical conditions Other medical conditions Non-obstetric 130 0.3
Urinary non-infectious Urinary non-infectious Non-obstetric 78 0.2
Anesthesia complications Anesthesia complications* Obstetric 64 0.2
Version/malposition Version/malposition* Obstetric 71 0.2
Hematology Hematology NOS Non-obstetric 21 0.1
Sepsis Sepsis NOS Non-obstetric 24 0.1
CNS infection CNS infection Non-obstetric 23 0.1
Endocrine Thyroid (n=42) Non-obstetric 60 0.1
  Endocrinolgy NOS (n=18)      
Breast NOS Breast NOS Non-obstetric 29 0.1
Cellulitis Cellulitis Non-obstetric 55 0.1
Cancer Cancer Non-obstetric 18 0.0
Intrauterine infection Intrauterine infection* Obstetric 12 0.0
Varicose veins Varicose veins Non-obstetric 2 0.0
*antepartum only +post-partum only **Antepartum anemia (n=93) was categorized as non-obstetric complications but was considered obstetric post-partum (n=193) *+Antepartum diabetes mellitus (n=1456) was considered as obstetric complication but was considered non-obstetric post-partum (n=27) 1ICD-9 codes for each group available upon request

Table 1: Primary discharge diagnosis grouping variables and sample size for all antepartum and post-partum admissions1.

  Obstetric
(N=25,791)
Non-obstetric
(N=9,275)
P value
Maternal age (years)* 26.9 (5.9) 25.6 (6.2) <0.001
Race      
 African-American 10.6 9.4 <0.001
 Caucasian 33.2 31.1  
 Hispanic 47.8 53.7  
 Asian 6.2 3.8  
 Other 2.3 1.9  
Payer     <0.001
 Private Insurance 40.5 30.7  
 Medicaid 53.7 57.6  
 Self-pay 3.4 6.3  
 Other 2.4 5.4  
Weekend admission 20.0 24.1 <0.001
* Mean (standard deviation)

Table 2: Maternal characteristics of the antepartum hospitalizations and the frequency of weekend admissions by obstetric and non-obstetric indications.

  N Percent of total Antepartum admissions Total charges in millions of dollars Percent of total Antepartum charges
Preterm labor 9060 25.78 106.0 20.20
Pregnancy NOS 6531 18.59 97.0 18.48
Urinary tract infection 5057 14.39 117.3 22.36
Hyperemesis 2847 8.10 37.8 7.20
Vaginal bleeding 1963 5.57 22.3 4.25
Hypertension 1664 4.74 15.9 3.03
Diabetes mellitus 1456 4.14 19.1 3.64
Psychiatric/substance abuse 888 2.53 12.4 2.37
Incompetent cervix 699 1.99 14.7 2.80
Infection NOS 670 1.91 14.0 2.67
PROM 628 1.79 8.3 1.59
Gynecology 584 1.66 9.4 1.80
Fetal indications 584 1.66 6.1 1.17
Chronic renal disease 351 1.00 4.2 0.81
Injury 299 0.85 7.6 1.44
Anemia 193 0.55 4.1 0.78
Cardiac 177 0.50 3.4 0.66
Multifetal pregnancy 162 0.46 2.5 0.48
PE/DVT 160 0.46 3.5 0.67
Abdominal pain/back pain 136 0.39 2.0 0.38
Pulmonary 126 0.36 2.4 0.45
Postdates 114 0.32 0.4 0.08
Appendicitis 109 0.31 2.2 0.41
Gallbladder/pancreas 103 0.29 1.7 0.33
Other medical conditions 92 0.26 1.8 0.35
Neurology 87 0.25 1.4 0.26
GI 77 0.23 1.2 0.21
Urinary non-infectious 73 0.21 0.9 0.16
Version/malposition 71 0.20 0.5 0.10
Endocrine 40 0.15 1.2 0.22
Cellulitis 47 0.13 0.7 0.13
Breast NOS 19 0.05 0.3 0.05
Hematology NOS 18 0.05 0.3 0.06
CNS infection 18 0.05 0.7 0.14
Cancer 16 0.05 0.9 0.17
Intrauterine infection 12 0.03 0.2 0.04
Sepsis 12 0.03 0.3 0.06
Varicose veins 1 0.00 0.0 0.00

Table 3: Frequency of the primary antepartum diagnoses, total hospital charges for each primary diagnosis, and relative contribution of each primary diagnosis to total antepartum charges.

For the 5,235 postpartum admissions, we determined that 28.7% (n=1,476) were for non-obstetric-related conditions. Total hospital charges for postpartum hospitalizations were 117.6 million dollars,with 32.9% (38.7 million dollars) for non-obstetrical indications. The maternal characteristics of the postpartum admissions as well as the percent of admissions which occurred on a weekend by obstetric and non-obstetric indications for hospitalization are presented in Table 4. In general, non-obstetric related admissions were older, more often Caucasian, with a higher frequency of weekend admissions compared to obstetrical hospitalizations. Table 5 presents the frequency of each primary diagnosis variable for all postpartum admissions along with the percent of total postpartum charges attributable to each diagnosis. Infectious complications of delivery (endometritis: 16.0% and wound infection: 12.9%) accounted for the majority of total (both obstetric and non-obstetric) post-partum admissions and hospital charges. The most common non-obstetric indication for admissions was psychiatric/ substance abuse disorders (6.9%), however cardiac conditions were the largest non-obstetric contributor to total postpartum charges (6.4%). The percentages of the most common obstetric and non-obstetric indications for hospitalization with associated charges are presented in Figures 3 and 4. While psychiatric/substance abuse disorders and urinary tract infections were the most common non-obstetric conditions requiring postpartum hospitalization, other conditions with significant morbidity and mortality such as cardiac complications, pulmonary embolism/deep venous thrombosis and neurological complications were significant contributors to all non-obstetric postpartum hospitalizations and charges.

womens-health-care-postpartum-obstetric

Figure 3: Distribution of most common postpartum obstetric indications for admission with associated charges.

womens-health-care-post-partum

Figure 4: Distribution of most common post-partum non-obstetric indications for admission with associated charges.

  Obstetric
(N=3,759)
Non-obstetric
(N=1,476)
P value
Maternal age (years)* 28.1 (6.9) 29.6 (7.3) <0.001
Race      
 African-American 9.3 12.9 <0.001
 Caucasian 34.6 40.3  
 Hispanic 46.7 38.1  
 Asian 6.8 6.6  
 Other 2.6 2.2  
Payer     <0.001
 Private Insurance 47.4 44.8  
 Medicaid 48.6 46.2  
 Self-pay 2.1 4.0  
 Other 1.8 5.0  
Weekend admission 20.0 24.1 <0.001
* Mean (standard deviation)

Table 4: Maternal characteristics of the postpartum hospitalizations and the frequency of weekend admissions by obstetric and non-obstetric indications.

  N Percent of total postpartum admissions Total charges (millions of dollars) Percent of total postpartum charges
Pregnancy NOS 870 16.50 24.8 21.08
Endometritis 844 16.00 19.2 16.32
Wound infection 678 12.86 14.3 12.16
Vaginal bleeding 578 10.96 9.0 7.66
Hypertension 375 7.11 6.1 5.14
Psychiatric/substance abuse 363 6.88 4.5 3.83
Urinary tract infection 277 5.25 4.0 3.39
Mastitis 243 4.61 3.5 3.00
Cardiac 212 4.02 7.5 6.40
Infection NOS 165 3.13 3.5 3.01
PE/DVT 118 2.24 3.4 2.85
Anemia 96 1.82 1.3 1.10
Neurology 76 1.44 4.8 4.06
Anesthesia complications 64 1.21 0.8 0.69
Gynaecology 60 1.14 1.2 1.03
Other medical conditions 38 0.72 1.2 1.01
Pulmonary 35 0.66 1.7 1.45
Gallbladder/pancreas 33 0.63 0.9 0.80
GI 27 0.51 0.7 0.62
Diabetes mellitus 27 0.51 0.5 0.46
Injury 15 0.28 0.9 0.73
Abdominal pain/back pain 12 0.23 0.6 0.53
Sepsis 12 0.23 1.0 0.84
Appendicitis 10 0.19 0.5 0.40
Breast NOS 10 0.19 0.1 0.17
Cellulitis 8 0.15 0.8 0.67
Chronic renal disease 7 0.13 0.1 0.08
Endocrine NOS 6 0.11 0.3 0.23
Urinary non-infectious 5 0.09 0.1 0.10
CNS infection 5 0.09 0.1 0.08
Cancer 2 0.04 0.1 0.09
Varicose veins 1 0.02 0.0 0.01

Table 5: Frequency of the primary postpartum diagnoses, total hospital charges for each primary diagnosis, and relative contribution of each primary diagnosis to total postpartum charges.

Conclusions

In this population-based investigation of the primary diagnoses for admission in the antepartum and postpartum periods of pregnancy, we found a significant proportion (26.6%) to be non-obstetric in nature. As expected, preterm labor was the most common antenatal indication for admission (22.4%) with urinary tract infections being the most common non-obstetric antenatal indication for admission (13.2%). In the analysis of postpartum admissions, psychiatric or substance abuse problems were a significant contributor to all admissions (7.0%) and were the most common non-obstetric indication for hospitalization (24.0%). Urinary tract infections were often the indication for admission in both the antepartum (14.4%) and postpartum periods of pregnancy (5.6%). Pregnancy can be associated with significant maternal morbidity and mortality. For many women, this can result in increased outpatient visits or hospitalization. As noted in previous publications, pregnancy-related hospitalizations are a significant contributor to health care costs and overall utilization of the healthcare system (1-5). In this investigation, we found that the majority of maternal admissions (73.1%) and charges (63.8%) to be attributable to obstetrical conditions, however a significant proportion of charges were for non-obstetrical conditions in both the antepartum (36.9%) and postpartum periods of pregnancy (36.3%). In the postpartum period, we noted that a disproportionate amount of total hospital charges were for serious non-obstetric conditions including cardiac disorders, neurological complications and pulmonary embolism/deep venous thrombosis. The current investigation provides important information regarding current indications for hospitalization and healthcare utilization of resources during pregnancy. Our findings are consistent with previous publications that note preterm labor and urinary tract infections to be the most common obstetric and nonobstetric indications for antepartum admission [2,3]. Unlike previous reports, we attempted to determine the most common indications for admission according to when they occurred in pregnancy (antepartum or postpartum). Limited data is available about the indications for postpartum admission based upon large population data. As expected, endometritis, wound infection and vaginal bleeding constituted a large portion of obstetric related postpartum admissions. The contribution of psychiatric and substance abuse disorders to antepartum and postpartum admissions was surprising and warrants further investigation as this could be an area of focus to develop strategies to reduce their contribution to total admissions. Several limitations should be noted about our investigation. While we limited our analysis to only the primary discharge diagnosis reported with an admissions, several patients would be expected to have multiple indications for admission. As such, the primary diagnosis may not accurately reflect the indication for admission. However, given the limitations of secondary diagnosis codes, we felt only primary diagnoses should be used. Also, the stratification of admissions into antepartum and intrapartum are not ideal, particularly for those labeled as intrapartum admissions. Antepartum and intrapartum admissions were determined by the inclusion or absence of a delivery as part of the same admission. We expect that many women with significant antepartum complications would be admitted for an indication and not discharged prior to the onset of labor. In this investigation, those women would be categorized as intrapartum and not be included in the analysis. Also, a large percentage of women were categorized as pregnancy not otherwise specified (NOS) and could significantly impact the relative contribution of several of the individual categories. However, we feel that the sample size of the investigation still allows for a reasonable estimate of indications for admissions. Finally, hospitalizations do not encompass the entire spectrum of maternal morbidity. As such, this study is biased to report only conditions which were severe enough to warrant inpatient management.

This study highlights the significant number of women who become sick during or after pregnancy, particularly with non-obstetric complications. Other authors have also highlighted the emerging burden of medical complications during pregnancy, particularly cardiovascular complications, on maternal morbidity and mortality [8]. However, we also observed that many of these conditions, such as urinary tract infections might be preventable or treatable on an outpatient basis and should be the focus of future research. Of concern is the relatively large number of women who are admitted with psychiatric or substance abuse problems in the postpartum period.Additional investigations should focus on improved identification of at risk-women and early intervention.

References

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  2. Adams MM, Harlass FE, Sarno AP, Read JA, Rawlings JS (1994) Antenatal hospitalizations among enlisted servicewomen, 1987-1990. Obstet Gynecol 84: 35-39.
  3. Bacak SJ, Callaghan WM, Dietz PM, Crouse C (2005) Pregnancy-associated hospitalizations in the United States, 1999-2000. Am J Obstet Gynecol 195: 592-597.
  4. Bennett TA, Kotelchuck M, Cox CE, Tucker MJ, Nadeau DA (1998) Pregnancy-associated hospitalizations in the United States in 1991 and 1992: a comprehensive view of maternal morbidity. Am J Obstet Gynecol 178: 346-354.
  5. Franks AL, Kendrick JS, Olson DR, Atrash HK, Saftlas AF, et al. (1992) Hospitalization for pregnancy complications, United States, 1986 and 1987. Am J Obstet Gynecol 166: 1339-1344.
  6. Berg CJ, Callaghan WM, Syverson C, Henderson Z (2010) Pregnancy-Related Mortality in the United States, 1998 to 2005. Obstet Gynecol 116: 1302-1309.
Citation: Waters TP, Bailit JL (2012) Obstetric and Non-Obstetric Indications for Admission in the Antepartum and Postpartum Periods of Pregnancy. J Women’s Health Care 1:104.

Copyright: © 2012 Waters TP, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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