Incidence and Predictors of Maternal Cardiovascular Mortality and Severe Morbidity in the Netherlands: A Prospective Cohort Study

Claartje M Huisman,Jolien W Roos-Hesselink,Johannes J Duvekot,Joost J Zwart,Jos Van Roosmalen

doi:10.1371/journal.pone.0056494

Abstract

ObjectiveTo assess incidence and possible risk factors of severe maternal morbidity and mortality from cardiovascular disease in the Netherlands.DesignA prospective population based cohort study.SettingAll 98 maternity units in the Netherlands.PopulationAll women delivering in the Netherlands between August 2004 and August 2006 (n = 371,021)MethodsCases of severe maternal morbidity and mortality from cardiovascular disease were prospectively collected during a two-year period in the Netherlands. Women with cardiovascular complications during pregnancy or postpartum who were admitted to the ward, intensive care or coronary care unit were included. Cardiovascular morbidity was defined as cardiomyopathy, valvular disease, ischaemic heart disease, arrhythmias or aortic dissection. All women delivering in the same period served as a reference cohort.Main outcome measuresIncidence, case fatality rates and possible risk factors.ResultsIncidence of severe maternal morbidity due to cardiovascular disease was 2.3 per 10,000 deliveries (84/358,874). Maternal mortality rate from cardiovascular disease was 3.0 per 100,000 deliveries (11/358,874). Case fatality rate in women with severe maternal morbidity due to cardiovascular disease was 13% (11/84). Case fatality rate was highest in aortic dissection (83%). Pre-existing acquired or congenital heart disease was identified in 34% of women. Thirty-one percent of women were of advanced maternal age (>35 years of age) and 5 percent above 40 years of age. Possible risk factors for cardiovascular morbidity were caesarean section (either resulting in or as a result of cardiovascular disease), multiple pregnancy, prior caesarean section, non-Western ethnicity and obesity.ConclusionsIn the Netherlands cardiovascular disease is a rare cause of severe maternal morbidity with an incidence of 2.3 per 10,000 deliveries and a high case fatality rate of 13%. Cardiovascular complications develop mostly in women not known with cardiac disease pre-pregnancy.

Highlights

Cardiovascular disease complicates approximately 1–3% of pregnancies and is responsible for 10 to 15% of maternal mortality.[1,2,3] Since more women with congenital and acquired heart disease reach fertile age due to improved medical care, the incidence of cardiovascular disease in pregnancy is increasing.The UK Confidential Enquiries into Maternal and Child Health have identified cardiovascular disease as an increasingly important cause of indirect maternal death
Pre-existing acquired or congenital heart disease was identified in 34% of women
In the Netherlands cardiovascular disease is a rare cause of severe maternal morbidity with an incidence of 2.3 per 10,000 deliveries and a high case fatality rate of 13%

Summary

Introduction

The UK Confidential Enquiries into Maternal and Child Health have identified cardiovascular disease as an increasingly important cause of indirect maternal death. In the last two triennia ending in 2005 and 2008, cardiac disease was the most frequent cause of indirect maternal death with a maternal mortality rate (MMR) of 2.27 and 2,31 per 100,000 maternities, respectively.[3]. There was a decline in maternal deaths related to congenital heart disease (CHD) from 4.6 per million to 1.3 per million maternities in the triennia ending in 1996 and 2008, maternal mortality from acquired heart diseases (AHD) increased from 3.8 per million in 1996 to 21.8 per million maternities in 2008.[3,4,5,6]

Methods

Results

Conclusion