In-hospital Maternal Mortality Research Articles

Maternal and Fetal Outcomes in Pulmonary Hypertension During Pregnancy: A Contemporary Nationwide Analysis

BackgroundPulmonary hypertension (PH) disproportionately affects women, presenting challenges during pregnancy. Historically, patients with PH are advised to avoid pregnancy; however, recent reports have indicated that the incidence of adverse events in pregnant females with PH may be lower than previously reported. MethodsWe conducted a retrospective cohort study in pregnant patients with PH using the National Readmission Database from January 1, 2016, to December 31, 2020. PH was categorized according to the World Health Organization (WHO) classification. Primary endpoints include maternal mortality and 30-day non-elective readmission rate. Other adverse short term maternal (cardiovascular and obstetric) and fetal outcomes were also analyzed. ResultsAmong 9,922,142 pregnant women, 3,532 (0.04%) had pulmonary hypertension (PH), with Group 1 PH noted in 1,833 (51.9%), Group 2 PH in 676 (19.1%), Group 3 PH in 604 (17.1%), Group 4 PH in 23 (0.7%), Group 5 PH in 98 (2.8%), and multifactorial PH in 298 (8.4%). PH patients exhibited higher rates of adverse cardiovascular events (15.7% vs. 0.3% without PH, p < 0.001) and mortality (0.9% vs. 0.01% without PH, p < 0.001). Mixed PH and Group 2 PH had the highest prevalence of adverse cardiovascular events among WHO PH groups. Patients with PH had a significantly higher non-elective 30-day readmission rate (10.4% vs. 2.3%) and maternal adverse obstetric events (24.2% vs. 9.1%) compared to those without PH (p < 0.001) (Figure 1). ConclusionPregnant women with PH had significantly higher adverse event rates, including in-hospital maternal mortality (85-fold), compared to those without PH.

Nationwide study of in-hospital maternal mortality in Ecuador, 2015-2022.

This study aimed to analyze estimates of in-hospital delivery-related maternal mortality and sociodemographic factors influencing this mortality in Ecuador during 2015 to 2022. Data from publicly accessible registries from the Ecuadorian National Institute of Statistics and Censuses were analyzed. Maternal mortality ratios (MMRs) were calculated, and bivariate and multivariate logistic regression models were used to obtain unadjusted and adjusted odds ratios. There was an increase in in-hospital delivery-related maternal deaths in Ecuador from 2015 to 2022: MMRs increased from 3.70 maternal deaths/100 000 live births in 2015 to 32.22 in 2020 and 18.94 in 2022. Manabí province had the highest rate, at 84.85 maternal deaths/100 000 live births between 2015 and 2022. Women from ethnic minorities had a higher probability of in-hospital delivery-related mortality, with an adjusted odds ratio (AOR) of 9.59 (95% confidence interval [95% CI]: 6.98 to 13.18). More maternal deaths were also observed in private health care facilities (AOR: 1.99, 95% CI: 1.4 to 2.84). Efforts to reduce maternal mortality have stagnated in recent years. During the COVID-19 pandemic in 2020, an increase in maternal deaths in hospital settings was observed in Ecuador. Although the pandemic might have contributed to the stagnation of maternal mortality estimates, socioeconomic, demographic and clinical factors play key roles in the complexity of trends in maternal mortality. The results from this study emphasize the importance of addressing not only the medical aspects of care but also the social determinants of health and disparities in the health care system.

Early Versus Late Post Cesarean Section Warfarin Initiation and Increased Risk of Maternal Complications in Patients With Mechanical Heart Valves: A Randomized, Open-Label Pilot Study.

The timing of the reinstitution of warfarin after cesarean section (CS) delivery was not adequately addressed in the literature. This study aims to evaluate the risks of early versus late initiation of warfarin post-CS in patients with mechanical heart valves. This randomized, open-label cohort study included 114 pregnant women with mechanical heart valves planned to be delivered by CS at or after 28 weeks of gestation. Patients were randomly divided into two groups: Day-2-group, where warfarin was started on day 2, and Day-5-group, where warfarin was started on day 5 after CS. Maternal postoperative bleeding complications, mechanical valve thrombosis, need for blood transfusion or reoperation, and maternal mortality were identified. Ten women (8.8%) had 11 bleeding complications, of whom 2 patients (20%) had intraperitoneal hemorrhage (none in Day-2-group and 2 in Day-5-group), 3 patients (30%) had subcutaneous hematoma (none in Day-2-group and 3 in Day-5-group), and 6 patients (60%) had sub-rectus hematoma (3 in Day-2-group and 3 in Day-5-group). No mechanical valve thrombosis, other thromboembolic events, or in-hospital maternal mortality were reported. Despite the small number of events, the bleeding risk was lower in the group with early post-CS warfarin introduction than in the group with late warfarin introduction in patients with prosthetic heart valves. ClinicalTrials.gov Identifier: NCT04855110.

Abstract 12699: Impact of Mode of Delivery on Maternal and Fetal Outcomes in Pregnant Patients With Heart Failure or Pulmonary Hypertension

Introduction: Despite the existing guidelines, data on maternal, fetal, and obstetric outcomes associated with various modes of delivery in pregnant patients with heart failure (HF) or severe pulmonary hypertension (pHTN) is limited. Methods: This retrospective population based cohort study used Nationwide Readmission Database to identify all hospitalized pregnant patients who were primarily admitted for vaginal or cesarean delivery from 2011 to 2019. Pregnant patients with HF or pHTN were identified. Primary outcomes were inhospital maternal and fetal mortality. Result: 23,359 hospitalized pregnant patients with HF or pHTN were identified. Cesarean deliveries were performed more than vaginal deliveries (66.2% vs. 33.8%). Patients undergoing cesarean delivery had lower odds of fetal mortality [OR: 0.18 (0.07-0.45), p&lt;0.001] and postpartum hemorrhage than vaginal delivery. However, the odds of in-hospital maternal mortality [OR: 2.0 (1.07-3.77), p=0.03], ACS, and puerperal sepsis were higher in cesarean group than in vaginal delivery group. There were no differences in the odds of in-hospital stroke and DVT/PE between two groups. We found that 167 pregnant women would have to undergo cesarean delivery to have one inhospital maternal mortality (NNH=167), and 164 pregnant women would have to undergo cesarean delivery to prevent one fetal mortality (NNT=164). There were increased odds of all-cause readmissions within 6 months in patients who had cesarean delivery compared with those who had vaginal deliveries. There was no difference in risk of acute exacerbation of HF, readmission mortality, ACS, stroke, and DVT/PE between two groups at 6 months. Conclusion: In this retrospective multicentric cohort study, cesarean delivery was associated with lower fetal mortality but higher inhospital maternal mortality. Thus, unique features of each patient case should be considered via a multidisciplinary discussion before determining a preferred delivery method.

Case study: Contributory Factors to In-hospital Maternal Mortality in a Governmental Hospital in Khartoum State in 2006

Case study: Contributory Factors to In-hospital Maternal Mortality in a Governmental Hospital in Khartoum State in 2006

Black-White Disparities in Maternal In-Hospital Mortality According to Teaching and Black-serving Hospital Status

(Am J Obstet Gynecol. 2021;225:83.e1–9) From 1987 to 2018, the maternal mortality rate (MMR) in the United States rose from 7.2 per 100,000 live births to 17.4. Compared with white patients, Black patients have significantly higher maternal mortality rate (14.9 vs. 37.3 per 100,000 live births). There are multiple factors contributing to this disparity. Approximately 90% of preventable maternal mortality may be due to provider factors, and therefore it is important to identify provider factors that contribute to the higher MMR among Black patients. The authors hypothesized that racial disparities in in-hospital MMR would differ between teaching and nonteaching hospitals. Further they hypothesized that the disparity would be larger in hospitals that care for a lower proportion of Black patients.

Clinical characteristics and risk factors for maternal deaths due to COVID-19 in Brazil: a nationwide population-based cohort study.

BackgroundMonitoring the characteristics and associated factors for death among pregnant and postpartum women with COVID-19 is necessary. We investigated the clinical characteristics and risk factors associated with maternal deaths in a nationwide cohort of Brazil.MethodsThis was a population-based cohort of all pregnant and postpartum women hospitalised with COVID-19 notified to the Sistema de Informação de Vigilância Epidemiológica da Gripe of Brazil (SIVEP-Gripe), from February 2020 to September 2021. The primary outcome was time to in-hospital death, with risks factors analysed with univariable and multivariable Cox proportional hazards regression models.ResultsCumulative observation time was 248 821 person-days from hospital admission to the end of follow-up for 15 105 individuals. There were 1858 deaths (12.3%) for a maternal mortality rate of 7.5 (95% CI 7.1–7.8) per 1000 patients-days. The cumulative mortality increased over time. Black/Brown ethnicity had a higher risk of death than women self-identifying as White. Women in the North, Northeast, Central-West and Southeast regions had higher risk of death than women in the South region. The characteristics independently associated with death were a postpartum status on admission (adjusted HR 1.4 [95%CI 1.2–1.6]), pre-existing clinical conditions (adjusted HRs 1.2 [95%CI 1.1–1.3] for one and 1.3 [95%CI 1.1–1.5] for two comorbidities), hypoxemia on admission (adjusted HR 1.2 [95%CI 1.1–1.4]) and requiring non-invasive (adjusted HR 2.6 [95%CI 2.1–3.3]) or invasive ventilatory support (adjusted HR 7.1 [95%CI 5.6–9.2]).ConclusionIn Brazil, the in-hospital maternal mortality rate due to COVID-19 is high and the risk of death increases with the length of hospitalisation. Socio-demographic and biological factors are associated with an increased risk of maternal death. The presence of respiratory signs and symptoms should be considered as an early markers of disease severity and an adequate management is necessary. Our findings reinforce the need for vaccination of pregnant and postpartum women against COVID-19.

Effect of antithrombin III among patients with disseminated intravascular coagulation in obstetrics: a nationwide observational study in Japan.

Pregnant women may develop disseminated intravascular coagulation (DIC), possibly resulting in massive maternal haemorrhage and perinatal death. The Japan guideline recommends use of antithrombin III (ATIII) for DIC in obstetrics; however, its effect remains uncertain. The present study aimed to investigate the effect of ATIII for DIC in obstetrics, using a national inpatient database in Japan. Nationwide observational study. Japan. We used the Diagnosis Procedure Combination inpatient database to identify patients who delivered at hospital and were diagnosed with DIC from July 2010 to March 2018. Propensity score matching analyses were performed to compare in-hospital maternal mortality and hysterectomy during hospitalisation between users and non-users of ATIII on the day of delivery. In-hospital mortality, hysterectomy. A total of 9920 patients were enrolled, including 4329 patients (44%) who used ATIII and 5511 patients (56%) who did not use ATIII. One-to-one propensity score matching created 3290 pairs. In-hospital maternal mortality did not differ significantly between the propensity-matched groups (0.3% in the ATIII group versus 0.5% in the control group; odds ratio 0.73; 95% CI 0.35-1.54). A significantly lower proportion of patients in the ATIII group, compared with those in the control group, underwent hysterectomy during hospitalisation (5.3% versus 8.7%; absolute risk difference -2.9%; 95% CI -4.2 to -1.6%). Although the present study did not show a mortality-reducing effect of ATIII for patients with DIC in obstetrics, it may have clinical benefit in terms of reducing the number of patients undergoing hysterectomy. This study did not show mortality-reducing effect of antithrombin III for patients with DIC in obstetrics.

Diabetes in pregnancy and risk of near-miss, maternal mortality and foetal outcomes in the USA: a retrospective cross-sectional analysis.

The prevalence of diabetes in pregnant women has increased in the USA over recent decades. The primary aim of this study was to assess the association between diabetes in pregnancy and maternal near-miss incident, maternal mortality and selected adverse foetal outcomes. We conducted a retrospective, cross-sectional analysis among pregnancy-related hospitalizations in USA between 2002 and 2014. We examined the association between DM and GDM as exposures and maternal in-hospital mortality, maternal cardiac arrest, early onset of delivery, poor foetal growth and stillbirth as the outcome variables. Among the 57.3 million pregnant women in the study population, the prevalence of GDM and DM was 5.4 and 1.3%, respectively. We found that pregnant women with DM were three times more likely to experience cardiac arrest (OR=3.21; 95% CI=2.57-4.01) and in-hospital maternal death (OR=3.05; 95% CI=2.45-3.79), as compared to those without DM. Among pregnant women with GDM and DM, the risk for early onset of delivery was higher, compared to women without GDM or DM. A diagnosis of diabetes prior to pregnancy contributes significantly to the risk of maternal cardiac arrest, maternal mortality and adverse foetal outcomes.

Black-White disparities in maternal in-hospital mortality according to teaching and Black-serving hospital status

Maternal mortality is higher among Black than White people in the United States. Whether Black-White disparities in maternal in-hospital mortality during the delivery hospitalization vary across hospital types (Black-serving vs nonBlack-serving and teaching vs nonteaching) and whether overall maternal mortality differs across hospital types is not known. The aims of this study were to determine whether risk-adjusted Black-White disparities in maternal mortality during the delivery hospitalization vary by hospital types (this is analysis of disparities in mortality within hospital types) and compare risk-adjusted in-hospital maternal mortality among Black-serving and nonBlack-serving teaching and nonteaching hospitals regardless of race (this is an analysis of overall mortality across hospital types). We performed a population-based, retrospective cohort study of 5,679,044 deliveries among Black (14.2%) and White patients (85.8%) in 3 states (California, Missouri, and Pennsylvania) from 1995 to 2009. A hospital discharge disposition of "death" defined maternal in-hospital mortality. Black-serving hospitals had at least 7% Black obstetrical patients (top quartile). We performed risk adjustment by calculating expected death rates using predictions from logistic regression models incorporating sociodemographics, rurality, comorbidities, multiple gestations, gestational age at delivery, year, state, and mode of delivery. We calculated risk-adjusted risk ratios of mortality by comparing observed-to-expected ratios among Black and White patients within hospital types and then examined mortality across hospital types, regardless of patient race. We quantified the proportion of Black-White disparities in mortality attributable to delivering in Black-serving hospitals using causal mediation analysis. There were 330 maternal deaths among 5,679,044 patients (5.8 per 100,000). Black patients died more often (11.5 per 100,000) than White patients (4.8 per 100,000) (relative risk, 2.38; 95% confidence interval, 1.89-2.98). Examination of Black-White disparities revealed that after risk adjustment, Black patients had significantly greater risk of death (adjusted relative risk, 1.44; 95% confidence interval, 1.17-1.79) and that the disparity was similar within each of the hospital types. Comparison of mortality, regardless of race, across hospital types revealed that among teaching hospitals, mortality was similar in Black-serving and nonBlack-serving hospitals. However, among nonteaching hospitals, mortality was significantly higher in Black-serving vs nonBlack-serving hospitals (adjusted relative risk, 1.47; 95% confidence interval, 1.15-1.87). Notably, 53% of Black patients delivered in nonteaching, Black-serving hospitals compared with just 19% of White patients. Among nonteaching hospitals, 47% of Black-White disparities in maternal in-hospital mortality were attributable to delivering at Black-serving hospitals. Maternal in-hospital mortality during the delivery hospitalization among Black patients is more than double that of White patients. Our data suggest this disparity is caused by excess mortality among Black patients within each hospital type, in addition to excess mortality in nonteaching, Black-serving hospitals where most Black patients deliver. Addressing downstream effects of racism to achieve equity in maternal in-hospital mortality will require transparent reporting of quality metrics by race to reduce differential care and outcomes within hospital types, improvements in care delivery at Black-serving hospitals, overcoming barriers to accessing high-quality care among Black patients, and eventually desegregation of healthcare.

Maternal hospital deaths: clinical and sociodemographic characteristics in Yucatán, México

Objective: Describe the clinical and sociodemographic characteristics of maternal deaths that occurred in a hospital in Yucatán, Mexico, as well as propose recommendations to improve the care of pregnant women in order to help reduce in-hospital maternal mortality. Material and methods: Retrospective, cross-sectional study conducted in a second-level care concentration hospital. The hospital database of maternal deaths that occurred during the 2014–2018 period was reviewed, as well as clinical summaries, maternal death reports, maternal death ratification forms, and hospital records. Results: There were 54 maternal deaths, the year with the highest percentage was 2018 with 15 (27.8%) deaths. Most of the women resided in municipalities with low and very low degrees of marginalization 23 (42.6%); 48 (88.9%) were engaged in housework; 13 had a history of previous abortion (24.1%), with prenatal control 18 (33.3%), used some contraceptive method 13 (24.1%); and 21 (38.9%) presented some complication during pregnancy. Direct maternal deaths were mainly hypertensive disorders with 9 (32.1%) deaths. Indirect maternal deaths were mainly due to heart disease and arteriovenous disorders 6 (30.0%). The Hospital Mortality Committee issued 98 (55.1%) recommendations to improve emergency care, of which 32 (32. 6%) were related to the training of health personnel in the first level of care; and 22 (22.5%) for the second level of care. Conclusion: It is important to improve the care of the pregnant woman through the permanent training of health personnel to detect warning signs in the prenatal consultation and care of the obstetric emergency, in order to fully detect the problems that arise in the care chain of patients. Likewise, the training and updating of medical personnel for the correct completion of the basic causes of maternal death according to IDC-10 will be necessary for the correct certification of deaths.

Epidemiology, Outcomes, and Risk Factors for Mortality in Critically Ill Women Admitted to an Obstetric High-Dependency Unit in Sierra Leone.

A better understanding of the context-specific epidemiology, outcomes, and risk factors for death of critically ill parturients in resource-poor hospitals is needed to tackle the still alarming in-hospital maternal mortality in African countries. From October 2017 to October 2018, we performed a 1-year retrospective cohort study in a referral maternity hospital in Freetown, Sierra Leone. The primary endpoint was the association between risk factors and high-dependency unit (HDU) mortality. Five hundred twenty-three patients (median age 25 years, interquartile range [IQR]: 21-30 years) were admitted to the HDU for a median of 2 (IQR: 1-3) days. Among them, 65% were referred with a red obstetric early warning score (OEWS) code, representing 1.17 cases per HDU bed per week; 11% of patients died in HDU, mostly in the first 24 hours from admission. The factors independently associated with HDU mortality were ward rather than postoperative referrals (odds ratio [OR]: 3.21; 95% CI: 1.48-7.01; P = 0.003); admissions with red (high impairment of patients' vital signs) versus yellow (impairment of vital signs) or green (little or no impairment of patients' vital signs) OEWS (OR: 3.66; 95% CI: 1.15-16.96; P = 0.04); responsiveness to pain or unresponsiveness on the alert, voice, pain unresponsive scale (OR: 5.25; 95% CI: 2.64-10.94; P ≤ 0.0001); and use of vasopressors (OR: 3.24; 95% CI: 1.32-7.66; P = 0.008). Critically ill parturients were predominantly referred with a red OEWS code and usually required intermediate care for 48 hours. Despite the provided interventions, death in the HDU was frequent, affecting one of 10 critically ill parturients. Medical admission, a red OEWS code, and a poor neurological and hemodynamic status were independently associated with mortality, whereas adequate oxygenation was associated with survival.

COVID-19 outbreak and decreased hospitalisation of pregnant women in labour

COVID-19 outbreak and decreased hospitalisation of pregnant women in labour

Maternal Bacteremia Caused by Staphylococcus Aureus With a Focus on Infective Endocarditis.

BackgroundSepsis is an important cause of morbidity and mortality in the pregnant patient. Injection drug use in pregnant populations has led to increased cases of bacteremia and infective endocarditis (IE) due to Staphylococcus aureus. We describe all cases of S. aureus bacteremia and IE among admitted pregnant patients at our hospital over a 6-year period.MethodsThis was a retrospective review of pregnant patients hospitalized with S. aureus bacteremia between April 2013 and November 2019. Maternal in-hospital mortality and fetal in-hospital mortality were the primary outcomes measured; the secondary outcome was the rate of 6-month maternal readmission.ResultsTwenty-seven patients were included; 15 (56%) had IE. The median (interquartile range [IQR]) age was 29 (25–33) years; 22 (82%) patients had methicillin-resistant S. aureus. Infection onset occurred at a median (IQR) of 29 (23–34) weeks’ gestation. Twenty-three (85%) mothers reported active injection drug use, and 21 (78%) were hepatitis C seropositive. Fifteen (56%) mothers required intensive care unit (ICU) care. Twenty-two (81%) patients delivered 23 babies; of the remaining 5 mothers, 3 (11%) were lost to follow-up and 2 (7%) terminated pregnancy. Sixteen (73%) babies required neonatal ICU care, and 4/25 (16%) infants/fetuses died during hospitalization. One (4%) mother died during hospitalization, and 7/26 (27%) mothers were readmitted to the hospital within 6 months for infectious complications.ConclusionsInjection drug use is a modifiable risk factor for S. aureus bacteremia in pregnancy. Fetal outcomes were poor, and mothers were frequently readmitted secondary to infection. Future targeted interventions are needed to curtail injection drug use in this population.

Mode of delivery is an independent risk factor for maternal mortality: a case-control study

Background and Objectives In contrast to the global trend, the maternal mortality ratio (MMR) in the United States has increased in recent decades. During this time, the cesarean section rate has concurrently and steadily increased. Herein, we sought to determine whether the mode of delivery is an independent risk factor for maternal in-hospital mortality. Materials and Methods We conducted a retrospective, population-based, 1:1 matched, case-control study on all births recorded in the Health – Care Cost and Utilization Project – Nationwide Inpatient Sample between 2005 and 2014. We compared cases of maternal mortality and survival on a number of clinical characteristics. We conducted two different multivariate logistic regression analysis models, obtaining the adjusted odds ratios to determine the independent effect of mode of delivery on maternal mortality relative to surviving controls. Results We found a total of 617 cases of maternal mortality, which corresponds to an in-hospital MMR of 6.9/100,000 in our cohort. We matched 617 controls to mortality cases by year and geographic location. Relative to surviving controls, cases of maternal mortality were older, more likely to be African American, of lesser income, more likely to use Medicaid as payment, to have prolonged admissions, and more likely to have severe obstetrical complications including preterm delivery, postpartum hemorrhage, eclampsia, peripartum cardiomyopathy, pulmonary emboli, and disseminated intravascular coagulation (DIC). Relative to unassisted vaginal delivery, adjusted logistic regression analysis reveals no excess mortality observed with assisted vaginal delivery: OR 1.35, 95% CI [0.59–3.51]. However, after adjusting for demographic and obstetrical confounders, a significant risk of maternal mortality was observed with cesarean delivery: OR 3.21, 95% CI [2.80–3.61], p-value = .0001. This risk was more pronounced amongst primary cesarean deliveries: OR 5.72, 95% CI [4.92–6.51], p-value = .0001. Conclusion Cesarean delivery, and particularly primary cesarean delivery, is an independent risk factor for maternal in-hospital mortality. Measures taken to reduce the cesarean section rate may impact the rising maternal mortality ratio (MMR) in the United States.

Maternal mortality risk indicators: Case-control study at a referral hospital in Guinea

ObjectiveThis study aimed to describe intrapartum and postpartum exposures possibly associated with the risk of in-hospital maternal mortality in Guinea. Study DesignData were collected in the Western Sub-Saharan Africa setting at the university hospital in Conakry, Guinea, during 2016−2017. Case-control study design was applied. The cases comprised all intrapartum and postpartum maternal deaths recorded during the study period. The controls were selected by random sampling from patients discharged alive following hospitalization due to vaginal delivery or cesarean section. Maternal mortality ratio (MMR) was defined as a quotient of the number of maternal deaths per 100,000 live births. Multivariable logistic regression was applied to generate odds ratios (OR) and 95 % confidence intervals (95 %CI). ResultsA total of 10,208 live births and 144 maternal deaths were recorded. The MMR was at 1411 per 100,000 live births. The main causes of maternal death included postpartum hemorrhage (56 %), retroplacental hematoma (10 %), and eclampsia (9%). The ORs of maternal death were significantly elevated in case of transfer from another hospital (OR 24.60, 95 %CI 11.32–53.46), misoprostol-induced labor (OR 4.26, 95 %CI 2.51–7.91), non-use of partogram (OR 3.70, 95 %CI 1.31–5.20), duration of labor ≥24 h (OR 2.87, 95 %CI 1.35–5.29), and positive history of cesarean section (OR 2.54, 95 %CI 1.12–6.19). ConclusionTo stop preventable maternal mortality in Sub-Saharan Africa, continued efforts are needed to provide perinatal monitoring, to reorganize the obstetric reference system, and to decrease the number of avoidable cesarean sections. Furthermore, the internal supervision of misoprostol doses used for labor induction should be a priority.

Inpatient Maternal Mortality in the United States, 2002-2014.

Although prior studies of inpatient maternal mortality in the United States provide data on the overall rate and trend in inpatient maternal mortality, there are no published reports of maternal mortality data stratified by timing of its occurrence across the pregnancy continuum (antepartum, intrapartum, and postpartum). The study objective was to determine whether the maternal mortality rate, trends over time, self-reported race/ethnicity, and associated factors vary based on the timing of the occurrence of death during pregnancy. We conducted a cross-sectional analysis of the Nationwide Inpatient Sample database to identify pregnancy-related inpatient stays stratified by timing. Among women in the sample, we determined in-hospital mortality and used International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify comorbidities and behavioral characteristics associated with mortality, including alcohol, drug, and tobacco use. Joinpoint regression was used to calculate rates and trends of in-hospital maternal mortality. During the study period, there were 7,411 inpatient maternal mortalities among an estimated 58,742,179 hospitalizations of women 15-49 years of age. In-hospital maternal mortality rate stratified by race showed that African Americans died at significantly higher rates during antepartum, intrapartum, and postpartum periods compared to hospitalizations for Whites or Hispanics during the same time period. Although the postpartum hospitalization represents only 2% of pregnancy-related hospitalizations among women aged 15-49 years, hospitalization during this time period accounted for 27.2% of all maternal deaths during pregnancy-related hospitalization. Most in-hospital maternal mortalities occur after hospital discharge from child birth (postpartum period). Yet, the postpartum period continues to be the time period with the least maternal healthcare surveillance in the pregnancy continuum. African American women experience three times more in-hospital mortality when compared to their White counterparts.

Trends in Maternal and Fetal Outcomes Among Pregnant Women With Systemic Lupus Erythematosus in the United States: A Cross-sectional Analysis.

Although pregnancy in systemic lupus erythematosus (SLE) carries a high risk for mother and fetus, outcomes may be improving. To assess nationwide trends and disparities in maternal and fetal complications among pregnant women with SLE. Retrospective cohort study. United States, 1998 to 2015. Adult pregnant women with and without SLE who had hospitalizations recorded in the National Inpatient Sample (NIS) database. Outcome measures were in-hospital maternal mortality, fetal mortality, preeclampsia or eclampsia, caesarean sections, non-delivery-related admissions, and length of stay. To assess whether trends in outcomes over time differed between patients with SLE and those without SLE, logistic or linear regression with an interaction term between year and SLE (yes or no) was used. Nationwide population estimates incorporating sampling and poststratification weights were obtained. An estimated 93820 pregnant women with SLE and 78045054 without SLE were hospitalized in the United States from 1998 through 2015. Outcomes improved during those 18 years. In-hospital maternal deaths (per 100000 admissions) declined among patients with as well as those without SLE (442 vs. 13 for 1998 to 2000 and <50 vs. 10 for 2013 to 2015), although the decrease was greater in women with SLE (difference in trends, P < 0.002). The percentage of patients with SLE in all pregnancy-related, as well as delivery-related, admissions increased significantly. The sample for this analysis was identified by using diagnostic codes; detailed information on hospital-specific trends, SLE disease activity, and medications was not available. Race trends could not be analyzed. Given that NIS uses weighted estimates, the incidence of outcomes reported may not be exact. In this large study examining SLE and non-SLE pregnancies over 18 years, in-hospital maternal mortality and overall outcomes improved markedly, particularly among women with SLE. However, improvement is still needed, because SLE pregnancy risks remain high. None.

Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study

Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 per 100 000 population (IQR 0·2-2·0). Maternal mortality was 20 (0·5%) of 3684 patients (95% CI 0·3-0·8). Complications occurred in 633 (17·4%) of 3636 mothers (16·2-18·6), which were predominantly severe intraoperative and postoperative bleeding (136 [3·8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4·47 [95% CI 1·46-13·65]), and perioperative severe obstetric haemorrhage (5·87 [1·99-17·34]) or anaesthesia complications (11·47 (1·20-109·20]). Neonatal mortality was 153 (4·4%) of 3506 infants (95% CI 3·7-5·0). Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa. Medical Research Council of South Africa.

Incidence, aetiology and outcomes of obstetric-related acute kidney injury in Malawi: a prospective observational study

BackgroundObstetric-related acute kidney injury (AKI) is thought to be a key contributor to the overall burden of AKI in low resource settings, causing significant and preventable morbidity and mortality. However, epidemiological data to corroborate these hypotheses is sparse. This prospective observational study aims to determine the incidence, aetiology and maternal-fetal outcomes of obstetric-related AKI in Malawi.MethodsWomen greater than 20 weeks gestation or less than 6 weeks postpartum admitted to obstetric wards at a tertiary hospital in Blantyre, Malawi, and at high-risk of AKI were recruited between 21st September and 11th December 2015. All participants had serum creatinine tested at enrolment; those with creatinine above normal range (> 82 μmol/L) underwent serial measurement, investigations to determine cause of kidney injury, and were managed by obstetric and nephrology teams. AKI was diagnosed and staged by Kidney Disease Improving Global Outcomes (KDIGO) criteria. Primary outcomes were the incidence proportion and aetiology of AKI. Secondary outcomes were in-hospital maternal mortality, need for dialysis, renal recovery and length of stay; in-hospital perinatal mortality, gestational age at delivery, birthweight and Apgar score.Results354 patients were identified at risk of AKI from the approximate 2300 deliveries that occurred during the study period. Three hundred twenty-two were enrolled and 26 (8.1%) had AKI (median age 27 years; HIV 3.9%). The most common primary causes of AKI were preeclampsia/eclampsia (n = 19, 73.1%), antepartum haemorrhage (n = 3, 11.5%), and sepsis (n = 3, 11.5%). There was an association between preeclampsia spectrum and AKI (12.2% AKI incidence in preeclampsia spectrum vs. 4.3% in other patients, p = 0.015). No women with AKI died or required dialysis and complete renal recovery occurred in 22 (84.6%) cases. The perinatal mortality rate across all high-risk admissions was 13.8%. AKI did not impact on maternal or fetal outcomes.ConclusionsThe incidence of AKI in high-risk obstetric admissions in Malawi is 8.1% and preeclampsia was the commonest cause. With tertiary nephrology and obstetric care the majority of AKI resolved with no effect on maternal-fetal outcomes. Maternal-fetal outcomes in Sub-Saharan Africa may be improved with earlier detection of hypertensive disease in pregnancy.