Cause Of Pregnancy-related Death Research Articles

Intimate Partner Violence and Women's Health.

Intimate partner violence affects 15-71% of women over their lifetime, resulting in significant stress, negative health effects, and negative economic effects. Features include physical and sexual abuse as well as psychological abuse and controlling behaviors such as reproductive coercion or stalking. Intimate partner violence can occur in both heterosexual and same-sex relationships, though the risk may be higher in lesbian, gay, bisexual, transgender, queer, or questioning couples. Pregnancy remains an especially risky time for escalating abuse and also provides a window of opportunity for screening and intervention. Victims experience many consequences of abuse, including physical injuries, traumatic brain injury, and chronic conditions such as headaches, insomnia, pelvic pain, depression, anxiety, and posttraumatic stress disorder. Homicide is an especially devastating consequence, with 40-45% of female victims killed by an intimate partner, and homicide remains an important cause of pregnancy-related death. Routine screening is recommended by the American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force, and obstetrician-gynecologists (ob-gyns) should remain vigilant for signs of abuse in their patients. Often the cycle of abuse makes it difficult for women to break free, and ob-gyns should continue to provide supportive care regardless of a woman's readiness to leave an abusive relationship.

Translating Maternal Mortality Review Into Quality Improvement Opportunities in Response to Pregnancy-Related Deaths in California

ObjectiveTo describe quality improvement opportunities (QIOs) associated with the five leading causes of pregnancy-related death in California and the methods by which the QIOs were collected by the California Pregnancy-Associated Mortality Review committee. DesignQualitative, descriptive design using thematic analysis. SampleA total of 907 QIOs identified from 203 cases of pregnancy-related deaths from cardiovascular disease, preeclampsia/eclampsia, hemorrhage, venous thromboembolism, and sepsis that occurred in California from 2002 to 2007. MethodsWe coded and thematically organized QIO data using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. We refer to the domains collectively as the 4R Framework. ResultsWe identified key themes across the five leading causes of death. In the Readiness domain, themes were related to overall facility readiness and helping women be prepared and knowledgeable about pregnancy and childbirth. Themes that emerged as central in the Recognition domain addressed the need for clinicians to better recognize risk factors and women’s signs and symptoms to ensure an accurate diagnosis. In the Response domain, three themes were predominant, and they were related to the coordination of care, timing of treatment, and follow-up care. ConclusionResults from our study show the utility and transferability of the first three domains of the 4R Framework as applied to quality improvement data from a large statewide maternal mortality review. Nursing leadership is necessary to support and guide national, statewide, and local efforts to improve the quality of maternity care through the implementation of quality improvement at the system, facility, clinician, and patient levels.

Severe cardiovascular morbidity in women with hypertensive diseases during delivery hospitalization

Cardiovascular disease is the leading cause of pregnancy-related death in the United States. Identification of short-term indicators of cardiovascular morbidity has the potential to alter the course of this devastating disease among women. It has been established that hypertensive disorders of pregnancy are associated with increased risk of cardiovascular disease 10-30 years after delivery; however, little is known about the association of hypertensive disorders of pregnancy with cardiovascular morbidity during the delivery hospitalization. We aimed to identify the immediate risk of cardiovascular morbidity during the delivery hospitalization among women who experienced a hypertensive disorder of pregnancy. This retrospective cohort study of women, 15-55 years old with a singleton gestation between 2008 and 2012 in New York City, examined the risk of severe cardiovascular morbidity in women with hypertensive disorders of pregnancy compared with normotensive women during their delivery hospitalization. Women with a history of chronic hypertension, diabetes mellitus, or cardiovascular disease were excluded. Mortality and severe cardiovascular morbidity (myocardial infarction, cerebrovascular disease, acute heart failure, heart failure or arrest during labor or procedure, cardiomyopathy, cardiac arrest and ventricular fibrillation, or conversion of cardiac rhythm) during the delivery hospitalization were identified using birth certificates and discharge record coding. Using multivariable logistic regression, we assessed the association between hypertensive disorders of pregnancy and severe cardiovascular morbidity, adjusting for relevant sociodemographic and pregnancy-specific clinical risk factors. A total of 569,900 women met inclusion criteria. Of those women, 39,624 (6.9%) had a hypertensive disorder of pregnancy: 11,301 (1.9%) gestational hypertension; 16,117 (2.8%) preeclampsia without severe features; and 12,206 (2.1%) preeclampsia with severe features, of whom 319 (0.06%) had eclampsia. Among women with a hypertensive disorder of pregnancy, 431 experienced severe cardiovascular morbidity (10.9 per 1000 deliveries; 95% confidence interval, 9.9-11.9). Among normotensive women, 1780 women experienced severe cardiovascular morbidity (3.4 per 1000 deliveries; 95% confidence interval, 3.2-3.5). Compared with normotensive women, there was a progressively increased risk of cardiovascular morbidity with gestational hypertension (adjusted odds ratio, 1.18; 95% confidence interval, 0.92-1.52), preeclampsia without severe features (adjusted odds ratio, 1.96; 95% confidence interval, 1.66-2.32), preeclampsia with severe features (adjusted odds ratio, 3.46; 95% confidence interval, 2.99-4.00), and eclampsia (adjusted odds ratio, 12.46; 95% confidence interval, 7.69-20.22). Of the 39,624 women with hypertensive disorders of pregnancy, there were 15 maternal deaths, 14 of which involved 1 or more cases of severe cardiovascular morbidity. Hypertensive disorders of pregnancy, particularly preeclampsia with severe features and eclampsia, are significantly associated with cardiovascular morbidity during the delivery hospitalization. Increased vigilance, including diligent screening for cardiac pathology in patients with hypertensive disorders of pregnancy, may lead to decreased morbidity for mothers.

Review article: Pulmonary embolism in pregnancy: suspicion, diagnosis and therapy

During pregnancy the haemostatic system is progressively activated to prepare the haemostatic needs of delivery and postpartum Blood hypercoagulability endothelial injury and stasis of blood flow predispose to thrombus formation Pulmonary embolism is a complication of venous thrombosis and is a leading cause of pregnancy related deaths at any trimester It is extremely common disorder without specific clinical features The physician is called to suspect the disorder and give a prompt diagnosis and therapy to avoid the lethal condition Delays in pulmonary embolism diagnosis and therapy are common and represent an important issue nbsp

718: Drug-related maternal deaths in Utah, 2013-2016

The Utah Perinatal Mortality Review is a multi-disciplinary committee that reviews all maternal and infant deaths in Utah. We described causes of maternal deaths in Utah from 2013-16, and evaluated the impact of committee classification of drug-related deaths as pregnancy-related (rather than pregnancy-associated) beginning in 2015. Retrospective review of all Utah maternal deaths from 2013-16. Pregnancy-associated (PA) death defined as death of a woman during pregnancy or within one year of the end of pregnancy, regardless of cause. Pregnancy-related (PR) death defined as death of a woman in the same time period, from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy. Accidental drug-related deaths included deaths from prescribed and illicit drugs. Contributing factors, defined by Centers for Disease Control and Prevention, were identified for each death. Beginning in 2015, the Committee classified accidental drug-related deaths as PR given mounting evidence that substance use disorder (SUD) and mental health (MH) conditions may be aggravated during pregnancy and in the post-partum period. To assess the impact of reclassifying accidental drug-related death as PR, we compared the PR mortality ratio in Utah in 2013-2016 using test of trend. In 2015-2016, 40 PA deaths and 26 PR deaths occurred: accidental drug toxicity was the leading cause of both PA (n=10, 25%) and PR (n=10, 38%) death (Figure 1). In 2015-2016, all women with accidental drug-related deaths had MH conditions and 80% of these deaths occurred 43-365 days postpartum. For all PA deaths (n=40), contributing factors included SUD (n=18, 45%), mental health conditions (n=16, 40%) and clinical issues, namely inadequate screening and treatment for SUD and MH conditions (n=15, 38%). In 2013-2014, there were 44 PA deaths. Leading causes were motor vehicle accident (n=10, 20%) followed by accidental drug-related death (n=7, 17.5%) (Figure 1). From 2013-2016, there was no significant increase in PR deaths attributable to reclassification of drug-related deaths as PR (p=0.06) (Figure 2). Accidental drug-related death was the most common identifiable cause of PR death in Utah in 2015-6 following reclassification of drug-related deaths as PR. Effective interventions aimed at identifying and treating pregnant and postpartum women with SUD and MH conditions are imperative.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

248: Leading causes of maternal mortality at an inner-city Hospital, 1949-2017

The purpose of this study was to characterize the causes of pregnancy-related and pregnancy- associated maternal deaths at a large safety-net hospital from 1949 - 2017 Death summaries, autopsy reports and previously collected data were reviewed for maternal deaths for time intervals spanning from January 1949 through December 2017. The intervals assessed were 1949-1971 (Interval 1) and 1972-2017 (Interval 2). The causes and incidence of pregnancy-related and pregnancy-associated deaths were ascertained and specified as: hemorrhage, cardiovascular disease, cardiomyopathy, hypertensive disorders of pregnancy, other medical non-cardiovascular disease, infection/sepsis, accidental, homicide and suicide. Chi-square and Fisher exact test were used to test the relationship between time intervals and causes of death. The leading cause of pregnancy-related deaths in interval 1 was infection/sepsis, accounting for 27%. The leading cause of pregnancy-related death in interval 2 was hypertensive disorders of pregnancy, accounting for 23% of pregnancy-related deaths. The percentage of pregnancy-related deaths due to infection/sepsis dropped significantly (p < .001) between the time intervals from 27% to 7%. The leading cause of pregnancy-associated deaths in interval 1 was accidental deaths, accounting for 21% of deaths, and was homicide during interval 2, accounting for 28% of pregnancy-associated deaths. The percentage of pregnancy-associated deaths due to homicide increased significantly (p < .05) between the time intervals from 9% to 28%. Over time, there has been a decrease in pregnancy-related deaths due to infectious causes, and an increase in pregnancy-associated deaths due to homicides at our hospital. The increase in deaths from homicide highlights the importance of screening for domestic violence and promoting public health initiatives to improve safety. The decrease in deaths due to infections points to successful intervention and subsequent reduction of a major contributor to maternal mortality. Since 1972, the leading cause of pregnancy-related deaths in our hospital is hypertensive disorders of pregnancy. This warrants further investigation and implementation of effective protocols to prevent maternal deaths related to hypertensive disorders of pregnancy.

298: Pregnancy-related death review of ten years - Florida 2007-2016

Objective: The U.S. pregnancy-related mortality ratio (PRMR) increased since 2004. Since 1999, Florida has performed systematic review of pregnancy-related deaths (PRDs). One goal has been to identify opportunities for prevention. We sought to describe the PRMR trend in Florida and record share the risk factors associated with PRDs. Study Design: The Florida Pregnancy Associated Mortality Review Committee (PAMR) identifies pregnancy- associated deaths by linking death certificates of reproductive age women to birth and fetal death certificates as well as Florida prenatal screens. Health records of possible PRDs are abstracted, reviewed and assessed by the multi -disciplinary PAMR team. PRD cases from 2007-2016 were analyzed for PRMR trend as well as risk factors. Results: In 2007-2016, Florida experienced 406 PRDs and 2,217,018 live births. Florida’s PRMR fluctuated from a high of 26.2 deaths per 100,000 live births in 2009, to 12.9 in 2016; 2016 is the lowest PRMR since 1999. Although not significant, there was a trend towards a reduced PRMR from 2009 through 2016. For the period 2007-2016, five causes of death accounted for 68% of PRDs: hemorrhage (21%), infection (15%), hypertensive disorders (14%), cardiomyopathy (9%), and thrombotic embolism (8%). Risk factors associated with PRD were class III obesity (RR 5.7), cesarean delivery (RR 4.2), age 35 or older (RR 3.0), no prenatal care (RR 2.7), non-Hispanic black (RR 2.7), and high school or less education (RR 1.4). PRDs due to ectopic pregnancy and flu-like infections increased between 2009 and 2013. Conclusion: Contrary to an increasing national trend, Florida’s PRMR trend declined between 2009 and 2016. Hemorrhage and infection were leading causes of PRDs. Obesity and cesarean delivery were leading risk factors. This may reflect combined Florida activities including Florida PAMR efforts, grass roots efforts of the Florida Perinatal Quality Collaborative, and efforts from other professional and community organizations. Florida PAMR should continue focusing on developing Urgent Maternal Mortality Messages, other educational efforts and promote needed women’s health policies and actions. The Florida Perinatal Quality Collaborative should continue to promote quality efforts that contribute to understanding leading causes, risk factors and disparities around maternal mortality.

How the quality of essential medicines is perceived and maintained through the pharmaceutical supply chain: A perspective from stakeholders in Nigeria.

Limited access to essential medicines for maternal and child health is a preventable cause of pregnancy-related deaths. This remains a predominant challenge in Nigeria, where sub-standard and falsified medications have historically been associated with maternal mortality. An in-depth understanding of perceptions surrounding quality assurance of essential medicines is pertinent for developing effective and sustainable interventions. To examine stakeholder perspectives on quality control of essential medicines for maternal and child health, while characterizing pharmaceutical distribution of medicines in Nigeria. Key informant interviews were conducted with a purposive sample of 26 participants between January and June 2018. Eligible participants included: pharmacists, pharmaceutical sales representatives (pharm reps), supply chain employees of pharmaceutical industries and regulatory agency personnel, working in the public or private health sector in either of the four states: Lagos, Enugu, Imo or Port-Harcourt. A 6-item survey was administered to collect demographic information on the participants. This was followed by 15 semi-structured questions to gather qualitative data on the subject matter. Verifying vendor credibility and use of identifiable regulatory markers were the most common methods adopted by pharmacists and pharm reps with the intent to control quality of medicines. Key challenges in assuring quality included: inefficiency of regulatory agencies, illicit sales of prescription medicines by patent medicine vendors, existence of open markets and failed policy implementation. While pharmacists and pharm reps solicited improved regulations and policy implementation; NAFDAC personnel primarily recommended an increased government funding to improve their efficiency. Beyond stakeholder recommendations, a fervent and consistent commitment on the part of the government is needed to improve quality assurance in Nigeria's pharmaceutical system. Public-private partnerships should be explored to address funding limitations to quality assurance. Future studies need to examine challenges and opportunities surrounding policy implementation, and regulatory enforcement in pharmaceutical distribution.

Review of Cardiovascular Drugs in Pregnancy.

Cardiovascular disease is now the leading cause of pregnancy-related deaths in the United States. Increasing maternal mortality in the United States underscores the importance of proper cardiovascular management. Significant physiological changes during pregnancy affect the heart's ability to respond to pathological processes such as hypertension and heart failure. These physiological changes further affect the pharmacokinetic and pharmacodynamic properties of cardiac medications. During pregnancy, these changes can significantly alter medication efficacy and metabolism. This article systematically reviews the literature on safety, efficacy, pharmacokinetics, and pharmacodynamics of cardiovascular drugs used for hypertension and heart failure during pregnancy and lactation. The 2017 American College of Cardiology/American Heart Association hypertension guidelines recommend transitioning pregnant patients to methyldopa, nifedipine, or labetalol. Heart failure medications, including beta-blockers, furosemide, and digoxin, are relatively safe and can be used effectively. Medications that block the renin angiotensin-aldosterone system have been shown to be beneficial in the general population; however, they are teratogenic and, therefore, contraindicated in pregnancy. Cardiovascular medications can also enter breast milk and, therefore, care must be taken when selecting drugs during the lactation period. A summary of the safety of drugs during pregnancy and lactation from an online resource, LactMed by the National Library of Medicine's TOXNET database, is included. High-risk pregnant patients with cardiovascular disease require a multispecialty team of doctors, including health care providers from obstetrics and gynecology, maternal fetal medicine, internal medicine, cardiovascular disease specialists, and specialized pharmacology expertise.

Placental Ischemia‐Induced Hypertension Is Abolished by Adrenergic Receptor Blockade

Hypertensive disorders of pregnancy are the number one cause of pregnancy‐related deaths in the United States. Preeclampsia is a disorder of maternal hypertension and vascular dysfunction presenting in the second half of pregnancy along with fetal growth restriction. Currently, there are no steadfast therapies besides early delivery of the fetus and ischemic placenta, which releases pro‐hypertensive factors into the maternal circulation. The sympathetic nervous system might be a novel target in treating preeclampsia, as sympathetic nervous activity is found to be increased in preeclamptic vs. normal pregnant women. However, it is unknown if the sympathetic nervous system mediates the development of placental ischemia‐induced hypertension. In this study, the hypothesis was tested that adrenergic receptor blockade prevents placental ischemia‐induced hypertension. Wistar Hannover rats were randomized to receive reduced uterine perfusion pressure (RUPP, N=15) or Sham RUPP (N=20) surgeries on gestational day 14 and examined at day 19. In RUPP vs. Sham rats, respectively, mean arterial blood pressure (MAP) was increased (121 ± 3 vs. 102 ± 1 mmHg, P&lt;0.05) without a change in heart rate (421 ± 7 vs. 423 ± 4 bpm). Average fetal weights (1.87 ± 0.04 vs. 2.11 ± 0.03 g) and placental weights (0.50 ± 0.02 vs. 0.57 ± 0.01 g) were lower (P&lt;0.05) in RUPP dams. In RUPP over Sham rats, vasoconstriction induced by the alpha‐adrenergic receptor agonist, phenylephrine, was greater in isolated renal interlobar arteries (Emax: 322 ± 19 vs. 251 ± 12 % of KCl response). The Emax response to KCl was not different between RUPP or Sham rats, in sequence: 100 ± 24 vs. 87 ± 14 % increase in force. A subset of RUPP (N=9) and Sham (N=9) rats received combined terazosin and propranolol (3 mg/kg per day of each, subcutaneous osmotic minipump) to block alpha‐ and beta‐adrenergic receptors, respectively, beginning the day of surgery on gestational day 14. By day 19, adrenergic blockade abolished the development of hypertension in RUPP rats (105 ± 2 mmHg, P&lt;0.05) and reduced their heart rate (343 ± 21 bpm, P&lt;0.05) with a lesser reduction detected in treated Sham rats for MAP (97 ± 2 mmHg, P&lt;0.05) and heart rate (387 ± 9 bpm, P&lt;0.05). Treatment did not alter average fetal weights (1.89 ± 0.05 and 2.11 ± 0.03 g) or placental weights (0.47 ± 0.02 and 0.50 ± 0.03 g) in RUPP and Sham rats, in turn, compared to their untreated counterparts. In conclusion, placental ischemia‐induced hypertension depends on activation of the sympathetic nervous system. The mechanisms responsible for this enhanced sympathetic nerve activity and adrenergic receptor signaling remain unknown but are likely to involve factors released from the ischemic placenta.Support or Funding Information4R00HL130577‐02This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Evaluation of maternal serum ischemia modified albumin and total antioxidant status in ectopic pregnancy

Background: Ectopic pregnancies constitute about 2% of all pregnancies which are the leading cause of pregnancy-related deaths and a considerable cause of maternal morbidity. Oxidative stress can lead to a number of pregnancy related diseases including miscarriage, eclampsia and preterm labor. Ischemia modified albumin (IMA) which reflects the oxidative stress may be used as a marker for ectopic pregnancy. Our aim was to compare the levels of IMA and total antioxidant status (TAS) in ectopic and normal pregnancies and to understand if IMA can be used as a marker to diagnose ectopic pregnancy.Materials and methods: Our case–control study consisted of 38 women with ectopic and 42 women with normal pregnancy. IMA and TAS levels were determined in serum samples with an albumin–cobalt binding test and by commercially available kits, respectively. IMA levels were adjusted according to serum albumin levels. Index of oxidation (IOS) was calculated by dividing adjusted IMA (A-IMA) levels with TAS. A receiver operating characteristics (ROC) curve analysis was made and cut-off values for the biomarkers were investigated in SPSS 21.0 program (SPSS, Chicago, IL). Data were presented as mean ± standard deviation and a p value < .05 was accepted as statistically significant.Results: There was a statistically significant difference in IMA, A-IMA, and IOS levels between ectopic and normal pregnancies. Although TAS level was not different statistically, it was lower in ectopic pregnancy. According to ROC curve analysis, IOS had the largest area under curve. A cut-off value of 0.545 for IOS had 81.6% sensitivity and 59.5% specificity.Conclusions: According to our study, oxidative stress plays an important role in ectopic pregnancy and either A-IMA or IOS can be evaluated as a marker of ectopic pregnancy after further studies.

Pregnancy-Related Deaths, Florida, 1999-2012: Opportunities to Improve Maternal Outcomes.

Objectives To examine pregnancy-related deaths (PRDs) in Florida, to identify quality improvement (QI) opportunities, and to recommend strategies aimed at reducing maternal mortality. Methods The Florida Pregnancy-Associated Mortality Review (PAMR) Committee reviewed PRDs occurring between 1999 and 2012. The PAMR Committee determined causes of PRDs, identified contributing factors, and generated recommendations for prevention and quality improvement. Information from the PAMR data registry, and live births from Florida vital statistic data were used to calculate pregnancy-related mortality ratios (PRMR) and PRD univariate risk ratios (RR) with 95% confidence intervals (CI). Results Between 1999 and 2012, the PRMR fluctuated between 14.7 and 26.2 PRDs per 100,000 live births. The five leading causes of PRD were hypertensive disorders (15.5%), hemorrhage (15.2%), infection (12.7%), cardiomyopathy (11.1%), and thrombotic embolism (10.2%), which accounted for 65% of PRDs. Principal contributing factors were morbid obesity (RR = 7.0, 95% CI 4.9-10.0) and late/no prenatal care (RR = 4.2, 95% CI 3.1-5.6). The PRMR for black women was three-fold higher (RR = 3.3, 95% CI 2.7-4.0) than white women. Among the five leading causes of PRDs, 42.5% had at least one clinical care or health care system QI opportunity. Two-third of these were associated with clinical quality of care, which included standards of care, coordination, collaboration, and communication. The QI opportunities varied by PRD cause, but not by race/ethnicity. Conclusion Gaps in clinical care or health care systems were assessed as the primary factors in over 40% of PRDs leading the PAMR Committee to generate QI recommendations for clinical care and health care systems.

Partnering of Public, Academic, and Private Entities to Reestablish Maternal Mortality Review in Georgia.

The pregnancy-related mortality ratio in the United States has increased over the past 25 years. Georgia's pregnancy-related mortality ratio is among the highest in the United States. Confronted with this harsh reality, Georgia reestablished maternal mortality review as one strategy to address its high maternal mortality. To achieve a comprehensive process for review of maternal deaths involved securing the knowledge, resources, and support of physician experts, public health agencies and professional organizations as well as representatives in the state legislature. The six key steps in successfully reinstating maternal mortality review were 1) establishing a maternal mortality advisory committee, 2) developing a defined methodology for comprehensive case identification, 3) convening an introductory maternal mortality review committee meeting, 4) securing legislative protection for the committee, 5) conducting a mock mortality review, and 6) completing a formal first-year case review and producing a summary report of initial findings. This first case review revealed the leading causes of pregnancy-related deaths in Georgia as hemorrhage, hypertension, cardiac disease, embolism, and seizures. Our objective in this commentary is to share our experiences and advocate for engaging public, private, and academic partners in working on complex and multifactorial public health issues such as high maternal mortality.

Pregnancy-Related Mortality in the United States, 2011-2013.

To update national population-level pregnancy-related mortality estimates and examine characteristics and causes of pregnancy-related deaths in the United States during 2011-2013. We conducted an observational study using population-based data from the Pregnancy Mortality Surveillance System to calculate pregnancy-related mortality ratios by year, age group, and race-ethnicity groups. We explored 10 cause-of-death categories by pregnancy outcome during 2011-2013 and compared their distribution with those in our earlier reports since 1987. The 2011-2013 pregnancy-related mortality ratio was 17.0 deaths per 100,000 live births. Pregnancy-related mortality ratios increased with maternal age, and racial-ethnic disparities persisted with non-Hispanic black women having a 3.4 times higher mortality ratio than non-Hispanic white women. Among causes of pregnancy-related deaths, the following groups contributed more than 10%: cardiovascular conditions ranked first (15.5%) followed by other medical conditions often reflecting pre-existing illnesses (14.5%), infection (12.7%), hemorrhage (11.4%), and cardiomyopathy (11.0%). Relative to the most recent report of Pregnancy Mortality Surveillance System data for 2006-2010, the distribution of cause-of-death categories did not change considerably. However, compared with serial reports before 2006-2010, the contribution of hemorrhage, hypertensive disorders of pregnancy, and anesthesia complications declined, whereas that of cardiovascular and other medical conditions increased (population-level percentage comparison). The pregnancy-related mortality ratio and the distribution of the main causes of pregnancy-related mortality have been relatively stable in recent years.

Imaging for the exclusion of pulmonary embolism in pregnancy.

Pulmonary embolism is a leading cause of pregnancy-related death. An accurate diagnosis in pregnant patients is crucial to prevent untreated pulmonary embolism as well as unnecessary anticoagulant treatment and future preventive measures. Applied imaging techniques might perform differently in these younger patients with less comorbidity and altered physiology, who largely have been excluded from diagnostic studies. To determine the diagnostic accuracy of computed tomography pulmonary angiography (CTPA), lung scintigraphy and magnetic resonance angiography (MRA) for the diagnosis of pulmonary embolism during pregnancy. We searched MEDLINE and Embase until July 2015. We used included studies as seeds in citations searches and in 'find similar' functions and searched reference lists. We approached experts in the field to help us identify non-indexed studies. We included consecutive series of pregnant patients suspected of pulmonary embolism who had undergone one of the index tests (computed tomography (CT) pulmonary angiography, lung scintigraphy or MRA) and clinical follow-up or pulmonary angiography as a reference test. Two review authors performed data extraction and quality assessment. We contacted investigators of potentially eligible studies to obtain missing information. In the primary analysis, we regarded inconclusive index test results as a negative reference test, and treatment for pulmonary embolism after an inconclusive index test as a positive reference test. We included 11 studies (four CTPA, five lung scintigraphy, two both) with a total of 695 CTPA and 665 lung scintigraphy results. Lung scintigraphy was applied by different techniques. No MRA studies matched our inclusion criteria.Overall, risk of bias and concerns regarding applicability were high in all studies as judged in light of the review research question, as was heterogeneity in study methods. We did not undertake meta-analysis. All studies used clinical follow-up as a reference standard, none in a manner that enabled reliable identification of false positives. Sensitivity and negative predictive value were therefore the only valid test accuracy measures.The median negative predictive value for CTPA was 100% (range 96% to 100%). Median sensitivity was 83% (range 0% to 100%).The median negative predictive value for lung scintigraphy was 100% (range 99% to 100%). Median sensitivity was 100% (range 0% to 100%).The median frequency of inconclusive results was 5.9% (range 0.9% to 36%) for CTPA and 4.0% (range 0% to 23%) for lung scintigraphy. The overall median prevalence of pulmonary embolism was 3.3% (range 0.0% to 8.7%). Both CTPA and lung scintigraphy seem appropriate for exclusion of pulmonary embolism during pregnancy. However, the quality of the evidence mandates cautious adoption of this conclusion. Important limitations included poor reference standards, necessary assumptions in the analysis regarding inconclusive test results and the inherent inability of included studies to identify false positives. It is unclear which test has the highest accuracy. There is a need for direct comparisons between diagnostic methods, including MR, in prospective randomized diagnostic studies.

Abstract 132: Adrenergic Receptor Blockade Prevents Placental Ischemia-induced Hypertension

Hypertensive disorders of pregnancy are the number one cause of pregnancy-related deaths in the United States. Preeclampsia is a disorder of maternal hypertension and cardiovascular dysfunction typically presenting in the second half of pregnancy along with fetal growth restriction. There are no steadfast therapies besides early delivery of the fetus and ischemic placenta, which releases factors into the maternal circulation promoting hypertension. Although sympathetic nervous activity was found to be increased in preeclamptic versus normal pregnant women, it is unknown if sympathetic nervous system plays a role in placental ischemia-induced hypertension. To address this question, we tested the hypothesis that adrenergic receptor blockade prevents placental ischemia-induced hypertension. Wistar rats were randomized to receive reduced uterine perfusion pressure, (RUPP, n=6) or Sham (n=5) surgeries on gestational day 14 and examined at day 19. In RUPP vs Sham rats, respectively, mean arterial blood pressure (115 ± 4 vs 103 ±2 mmHg, P&lt;0.05) and the number of absorbed fetuses (6 ± 1 vs 1 ± 1, P&lt;0.05) were greater whereas average fetal weight was lower (1.7 ± 0.1 vs 2.0 ± 0.2, P&lt;0.05) with similar placental weights (0.49 ± 0.03 vs 0.52 ± 0.03). In RUPP vs Sham rats, renal cortical norepinephrine content (HPLC) was higher (183 ± 15 vs 150 ± 8 pg/mg wet weight, P&lt;0.05) and vasoconstriction to phenylephrine was greater in small, third order mesenteric arteries (Emax: 262 ± 19 vs 160 ± 26% of KCl response). A subset of RUPP rats (n=3) received terazosin and propranolol (3 mg/kg per day each, subcutaneous osmotic minipump) to block alpha- and beta-adrenergic receptors, respectively, beginning the day of RUPP surgery. At day 19, adrenergic blockade prevented the development of hypertension (100 ± 4 mmHg, P&lt;0.05) and did not alter number of fetal absorptions (8 ± 1). Average fetal weight was higher (2 ± 0.1, P&lt;0.05) and placental weight lower (0.41 ± 0.03, P&lt;0.05) compared to the untreated RUPP rats. In conclusion, placental ischemia-induced hypertension depends on activation of the sympathetic nervous system. The mechanism for this enhanced sympathetic nerve activity is unknown but may involve factors released from the ischemic placenta.

Pregnancy-Related Cardiovascular Deaths in California

Objective Maternal mortality rates rose markedly from 2002 to 2006 in California, prompting an in-depth maternal mortality review in a state that comprises one twelfth of the US birth cohort. Cardiovascular disease has emerged as the leading cause of pregnancy-related death in the United States. The primary aim of this analysis was to describe the incidence and type of cardiovascular disease as a cause of pregnancy-related mortality in California. The secondary aims were to describe racial/ethnic and socioeconomic disparities, risk factors, birth outcomes, timing of death and diagnosis, and signs and symptoms of cardiovascular disease and identify contributing factors. Study Design The California Pregnancy-Associated Mortality Review retrospectively examined a case series of 64 cardiovascular pregnancy-related deaths from 2002 through 2006. Two cardiologists independently reviewed complete inpatient and outpatient medical records including laboratory, radiology, electrocardiogram, chest X-ray, echocardiograms, and autopsy findings for each cardiovascular death and classified cause of death by type of cardiovascular disease. Demographic data, racial disparities, risk factors, signs and symptoms, timing of diagnosis and death, birth outcomes, and contributing factors were analyzed using bivariate comparisons with noncardiovascular pregnancy-related deaths and population-based data. Results Among 2,741,220 California women who gave birth, 864 died while pregnant or within 1 year of pregnancy; 257 of the deaths were deemed pregnancy related, and of these, 64 (25%) were attributed to cardiovascular disease. There were 42 deaths caused by cardiomyopathy, and the pregnancy-related mortality rate from cardiomyopathy was 1.54 per 100,000 births. Dilated cardiomyopathy existed in 29 cases, of which 15 met the definition of peripartum cardiomyopathy. Women with cardiovascular disease were more likely than women who died from noncardiovascular causes to be African-American (39.1% vs 16.1%; P P Conclusion African-American race, substance use, and obesity were risk factors for pregnancy-related cardiovascular disease mortality. Chronic disease prevention and better recognition and response to cardiovascular disease during pregnancy are needed to reduce maternal mortality.

Pregnancy-related cardiovascular deaths in California: beyond peripartum cardiomyopathy

Maternal mortality rates rose markedly from 2002 to 2006 in California, prompting an in-depth maternal mortality review in a state that comprises one twelfth of the US birth cohort. Cardiovascular disease has emerged as the leading cause of pregnancy-related death in the United States. The primary aim of this analysis was to describe the incidence and type of cardiovascular disease as a cause of pregnancy-related mortality in California. The secondary aims were to describe racial/ethnic and socioeconomic disparities, risk factors, birth outcomes, timing of death and diagnosis, and signs and symptoms of cardiovascular disease and identify contributing factors. The California Pregnancy-Associated Mortality Review retrospectively examined a case series of 64 cardiovascular pregnancy-related deaths from 2002 through 2006. Two cardiologists independently reviewed complete inpatient and outpatient medical records including laboratory, radiology, electrocardiogram, chest X-ray, echocardiograms, and autopsy findings for each cardiovascular death and classified cause of death by type of cardiovascular disease. Demographic data, racial disparities, risk factors, signs and symptoms, timing of diagnosis and death, birth outcomes, and contributing factors were analyzed using bivariate comparisons with noncardiovascular pregnancy-related deaths and population-based data. Among 2,741,220 California women who gave birth, 864 died while pregnant or within 1 year of pregnancy; 257 of the deaths were deemed pregnancy related, and of these, 64 (25%) were attributed to cardiovascular disease. There were 42 deaths caused by cardiomyopathy, and the pregnancy-related mortality rate from cardiomyopathy was 1.54 per 100,000 births. Dilated cardiomyopathy existed in 29 cases, of which 15 met the definition of peripartum cardiomyopathy. Women with cardiovascular disease were more likely than women who died from noncardiovascular causes to be African-American (39.1% vs 16.1%; P < .01) and more likely to use illicit substances (23.7% vs 9.4%; P < .01). Thirty-seven percent were obese and 20% had a concomitant diagnosis of hypertension or preeclampsia during pregnancy. Health care decisions in the diagnosis or treatment of cardiovascular disease during and after pregnancy contributed to the fatal outcomes. African-American race, substance use, and obesity were risk factors for pregnancy-related cardiovascular disease mortality. Chronic disease prevention and better recognition and response to cardiovascular disease during pregnancy are needed to reduce maternal mortality.

Pregnancy-related mortality in the United States, 2006-2010.

To update national population-level pregnancy-related mortality estimates and examine characteristics and causes of pregnancy-related deaths in the United States during 2006-2010. We used data from the Pregnancy Mortality Surveillance System and calculated pregnancy-related mortality ratios by year and age group for four race-ethnicity groups: non-Hispanic white, non-Hispanic black, Hispanic, and other. We examined causes of pregnancy-related deaths by pregnancy outcome during 2006-2010 and compared causes of pregnancy-related deaths since 1987. The 2006-2010 pregnancy-related mortality ratio was 16.0 deaths per 100,000 live births (20,959,533 total live births). Specific race-ethnicity pregnancy-related mortality ratios were 12.0, 38.9, 11.7, and 14.2 deaths per 100,000 live births for non-Hispanic white, non-Hispanic black, Hispanic, and other race women, respectively. Pregnancy-related mortality ratios increased with maternal age for all women and within all age groups, non-Hispanic black women had the highest risk of dying from pregnancy complications. Over time, the contribution to pregnancy-related deaths of hemorrhage, hypertensive disorders of pregnancy, embolism, and anesthesia complications continued to decline, whereas the contribution of cardiovascular conditions and infection increased. Seven of 10 categories of causes of death each contributed from 9.4% to 14.6% of all 2006-2010 pregnancy-related deaths; cardiovascular conditions ranked first. Relative to previous years, during 2006-2010, the U.S. pregnancy-related mortality ratio increased as did the contribution of cardiovascular conditions and infection to pregnancy-related mortality. Although the identification of pregnancy-related deaths may be improving in the United States, the increasing contribution of chronic diseases to pregnancy-related mortality suggests a change in risk profile of the birthing population. II.

Understanding maternal mortality from top-down and bottom-up perspectives: Case of Tigray Region, Ethiopia.

BackgroundUnacceptably high levels of preventable maternal mortality persist as a problem across sub–Saharan Africa and much of south Asia. Currently, local assessments of the magnitude of maternal mortality are not often made, so the best available information for health planning may come from global estimates and not reflect local circumstances.MethodsA community–based cross-sectional survey was designed to identify all live births together with all deaths among women aged 15–49 years retrospectively over a one–year period in six randomly selected districts of Tigray Region, northern Ethiopia. After birth and death identification, Health Extension Workers trained to use the WHO 2012 verbal autopsy (VA) tool visited households to carry out VAs on all deaths among women aged 15–49 years. All pregnancy–related deaths were identified after processing the VA material using the InterVA–4 model, which corresponds to the WHO 2012 VA. A maternal mortality ratio (MMR) was calculated for each District and expressed with a 95% confidence interval (CI).ResultsThe MMRs across the six sampled Districts ranged from 37 deaths per 100 000 live births (95% CI 1 to 207) to 482 deaths per 100 000 live births (95% CI 309 to 718). The overall MMR for Tigray Region was calculated at 266 deaths per 100 000 live births (95% CI 198 to 350). Direct obstetric causes accounted for 61% of all pregnancy–related deaths. Haemorrhage was the major cause of pregnancy–related death (34%). District–level MMRs were strongly inversely correlated with population density (r2 = 0.86).ConclusionThis simple but well–designed survey approach enabled estimation of maternal mortality in Tigray Region on a local, contemporary basis. It also provided insights into possible local variations in MMR and their determinants. Consequently, this approach could be implemented at regional level in other large sub–Saharan African countries, or at national level in smaller ones to monitor and evaluate maternal health service interventions.