Pregnancy-related Deaths Research Articles

National Partnership for Maternal Safety

(Abstracted from Anesth Analg, 123(4):942–949, 2016) According to the World Health Organization, 14.9% of maternal deaths in developed nations such as those of Europe and North America, Australia, New Zealand, and Japan are thought to involve embolism. In the United States alone, per the Centers for Disease Control and Prevention (2006–2010), approximately 9.3% of pregnancy-related deaths are a result of thrombotic pulmonary embolism.

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 11854: Nationwide In-hospital Outcomes of Pregnancy in Women With Single Ventricle Congenital Heart Disease

Introduction: Most patients with single ventricle (SV) congenital heart disease (CHD) are expected to survive to adulthood. Women with SV are often counseled against pregnancy; however, data on pregnancies in these women are lacking. We sought to evaluate in-hospital outcomes of pregnancy in women with SV. Methods: We used nationally representative data from 1998 to 2012 Nationwide Inpatient Sample database to identify patients ≥ 18 years of age admitted to the hospital with International Classification of Diseases-9th Revision codes for an intrauterine pregnancy and a diagnosis of either hypoplastic left heart syndrome, tricuspid atresia or common ventricle. A matched comparison group without a diagnosis of CHD or pulmonary hypertension was identified from the database. National estimates of hospitalizations were calculated. Length of stay (LOS), total hospital charges, and cardiovascular complications were analyzed and compared between groups. Charge data were adjusted to 2012 dollars. Results: There were 310 admissions of pregnant women with SV (63% with deliveries) and 1547 admissions in the control group (91% with deliveries). There was no change in the annual number of SV pregnancies during the study period. Vaginal delivery was more common in SV (74% vs 72%, p<0.001). LOS (4.6 [0.98] days vs 2.5 [0.07], p<0.001) and charges ($38,627 [11,918] vs $13,880 [631], p<0.0001) were higher in SV. SV deliveries occurred more commonly in teaching hospitals (78% vs 51%, p<0.001). Complications occurred in nearly all SV admissions and were more common in SV compared to controls. (Table) There were no deaths in either group. Conclusions: Pregnancies in women with SV are associated with increased hospital resource utilization and cardiovascular complications, though in-hospital pregnancy related death is rare. Vaginal delivery is common in these patients. These data suggest that pregnancy and vaginal delivery are well tolerated in women with SV.

Nicotinamide benefits both mothers and pups in two contrasting mouse models of preeclampsia

Preeclampsia (PE) complicates ∼5% of human pregnancies and is one of the leading causes of pregnancy-related maternal deaths. The only definitive treatment, induced delivery, invariably results in prematurity, and in severe early-onset cases may lead to fetal death. Many currently available antihypertensive drugs are teratogenic and therefore precluded from use. Nonteratogenic antihypertensives help control maternal blood pressure in PE, but results in preventing preterm delivery and correcting fetal growth restriction (FGR) that also occurs in PE have been disappointing. Here we show that dietary nicotinamide, a nonteratogenic amide of vitamin B3, improves the maternal condition, prolongs pregnancies, and prevents FGR in two contrasting mouse models of PE. The first is caused by endotheliosis due to excess levels in the mothers of a soluble form of the receptor for vascular endothelial growth factor (VEGF), which binds to and inactivates VEGF. The second is caused by genetic absence of Ankiryn-repeat-and-SOCS-box-containing-protein 4, a factor that contributes to the differentiation of trophoblast stem cells into the giant trophoblast cells necessary for embryo implantation in mice; its absence leads to impaired placental development. In both models, fetal production of ATP is impaired and FGR is observed. We show here that nicotinamide decreases blood pressure and endotheliosis in the mothers, probably by inhibiting ADP ribosyl cyclase (ADPRC), and prevents FGR, probably by normalizing fetal ATP synthesis via the nucleotide salvage pathway. Because nicotinamide benefits both dams and pups, it merits evaluation for preventing or treating PE in humans.

Deaths From Unintentional Injury, Homicide, and Suicide During or Within 1 Year of Pregnancy in Philadelphia.

To understand the effect of unintentional injuries (e.g., drug overdose), suicide, and homicide on pregnancy-associated death (death during or within 1 year of pregnancy). We analyzed all cases of pregnancy-associated death among Philadelphia, Pennsylvania, residents from 2010 to 2014, examining cause of death, contributing factors, and history of health care use. Approximately half (49%; 42 of 85) of pregnancy-associated deaths were from unintentional injuries (n = 31), homicide (n = 8), or suicide (n = 3); drug overdose was the leading cause (n = 18). Substance use was noted during or around events leading to death in 46% (31 of 67) of nonoverdose deaths. A history of serious mental illness was noted in 39% (32 of 82) of nonsuicide deaths. History of intimate partner violence (IPV) was documented in 19% (15 of 77) of nonhomicide deaths. Regardless of cause of death, approximately half of all decedents had an unscheduled hospital visit documented within a month of death. Unintentional injury, homicide, and suicide contribute to many deaths among pregnant and recently pregnant women. Interventions focused on substance use, mental health, and IPV may reduce pregnancy-associated and pregnancy-related deaths.

Pregnancy and death: An examination of pregnancyrelated deaths among adolescents in South Africa

Background. South Africa (SA)’s high adolescent fertility has been extensively studied. A pregnancy outcome that has not received sufficient attention in research is the causes of death among pregnant adolescents. Objectives. To examine levels and causes of adolescent maternal mortality in SA. Methods. A secondary data analysis of Death Notification Forms from 2006 to 2012 was carried out. SA General Household Surveys from 2006 to 2012 were used to ascertain the number of female adolescents in the population. Frequency distributions and life table techniques were employed. Results. An estimated 1 164 deaths have been recorded among pregnant adolescents between 2006 and 2012. Adolescent maternal and pregnancy-related mortality is lower than adult maternal and pregnancy-related mortality. The main causes of death among adolescents were hypertension (55.6% of all direct causes), abortion (17.6% of all indirect causes) and injuries (48.9% of all indirect causes). The probability of adolescents dying while pregnant without these causes is practically non-existent (range 0.002 - 0.150%). Conclusion. Policies and programmes should prioritise these pregnancy-related causes of death in order to further reduce such deaths among adolescents in SA.

Black Lives Matter: Claiming a Space for Evidence-Based Outrage in Obstetrics and Gynecology.

The authors reflect on the Black Lives Matter (BLM) social movement in relation to the pregnancy-related deaths of black women in the U.S., and it mentions evidence-based outrage, racial disparities in medical research, and a call for obstetricians and gynecologists to prioritize racial equity in women's health care in America. The use of the phrase BLM in medical literature is examined, along with issues such as family planning for black women, maternal fetal medicine, and infertility.

Unnatural pregnancy deaths in Las Vegas: A descriptive study

This study reports descriptive data assessing the prevalence of various risk factors and associations among pregnancy-related death by unnatural causes (PRUD), namely suicide, homicide and accidental causes in the city of Las Vegas. In 7215 women referred for autopsy, results showed PRUD 0.1% (n = 37) was more common in the Caucasian race 45.9% (n = 17), and ages 20–30 years 43.2% (n = 16). We also identified high prevalence of mental illness 51.3% (n = 19) and low prenatal care 37.8% (n = 14), particularly in our suicide cohort 100.0% (n = 13), and 15.3% (n = 2) respectively. Our study demonstrates the first investigation to identify the relationship between mental illness, particularly mood and substance disorders with pregnancy-related unnatural death.

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<0.05) and the number of absorbed fetuses (6 ± 1 vs 1 ± 1, P<0.05) were greater whereas average fetal weight was lower (1.7 ± 0.1 vs 2.0 ± 0.2, P<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<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<0.05) and did not alter number of fetal absorptions (8 ± 1). Average fetal weight was higher (2 ± 0.1, P<0.05) and placental weight lower (0.41 ± 0.03, P<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.

Provision of fertility services for women at increased risk of complications during fertility treatment or pregnancy: an Ethics Committee opinion.

This opinion addresses the ethics of providing fertility treatment to women at elevated risk from fertility treatment or pregnancy. Providers ethically may treat women at elevated risk provided that they are carefully assessed; that specialists in their medical condition are consulted as appropriate; and that patients are fully informed about risks, benefits, and alternatives, including oocyte and embryo donation, use of a gestational surrogate, not undergoing fertility care, and adoption. Providers also may conclude that the risks are too high for them to treat particular patients ethically; such determinations must be made in a medically objective and unbiased manner and patients must be fully informed of the decision. Counseling of women who wish to initiate fertility treatment with underlying medical conditions that confer increased risk during treatment or pregnancy should incorporate the most current knowledge available, being cognizant of the woman's personal determinants in relation to her reproductive desires. In such a way, both physician and patient will optimize decision making in an ethically sound, patient-supportive context.

Providing Oral Nutrition to Women in Labor: American College of Nurse-Midwives.

Historically, oral intake for women during labor has been limited to nothing by mouth or clear liquids only. These restrictions are based on the risk of aspiration during or after the administration of general anesthesia. While aspiration can be life threatening, older methods of anesthesia are rarely used in current intrapartum care, and evidence is inconclusive that withholding oral nutrition reduces the risk of gastric aspiration. Additionally, withholding oral nutrition may result in the development of ketosis and may potentially contribute to a woman's stress and dissatisfaction with the birth experience. The purpose of this Clinical Bulletin is to review the evidence related to this practice and provide recommendations to promote informed, shared decision making regarding oral intake during labor with women at low risk for gastric aspiration.

MATERNAL DEATH IN INDONESIA: FOLLOW-UP STUDY OF THE 2010 INDONESIA POPULATION CENSUS

Background: Among ASEAN countries, Indonesia is the country with high maternal mortality ratio (MMR) and unable to reach target of reduction of MMR. In order to reduce the MMR target, the government of Indonesia needs evidence to evaluate and design the maternal health program. Objective: The study aims to answers specific issues of who, when, where and why maternal death occurred in Indonesia in order to understand the effective policy and health program decisions. Methods: The 2010 Indonesia Population Census identified pregnancy-related deaths occurring in the household from 1 January 2009 until the date of census (May 2010). The follow-up study revisited almost half of households reporting pregnancy-related deaths to be accounted as samples (4167 of 8464). Basic information related to cause of death were collected by trained data collector using verbal autopsy approach. The information was converted to cause of death defined by medical doctor using WHO ICD-10 rules. The underlying cause of death was later analysed. Result: The highest risk of maternal death was adolescents who were pregnant under 15 years old. The maternal death mostly occurred at postpartum period (56%), 57 percent occurred at hospitals and 31.3 percent at home. Oedema, proteinuria and hypertensive disorder in pregnancy were at 27 percent, whereas complication during labour and delivery problems were accounted for 26 percent. The pattern of maternal causes of death varies between regions. Conclusion: Maternal health program has not been considered as general plan of intervention. It is imperative to consider considered by pattern of characteristics and cause of maternal death and region for effective interventions.

Does maternal obesity impact pregnancy-related deaths? Michigan experience

Obesity is a multifactorial non-communicable condition that has become a public health epidemic worldwide. The Fifth Millennium Development Goal established the goal of a 75% reduction in the maternal mortality ratio (MMR) between 1990 and 2015. Maternal mortality has been difficult to track over time. Obesity affects pregnancy in more than 50% of women of reproductive age in the state of Michigan; the potential impact of maternal obesity and pregnancy-related deaths (PRDs) has not been studied in Michigan. We conducted a secondary analysis of maternal death cases originally reviewed by the Michigan Maternal Mortality Review Committee from 2004 to 2006 seeking to evaluate the impact of maternal obesity on PRD. Two hundred and five maternal deaths occurred during the period of the study, 61 were classified as PRD. The observed occurrence of PRDs in the obese population was 36 cases while in the non-obese was 25 cases. The study showed a 3.7× risk of PRD in the obese parturient.

Women's Experiences Being Diagnosed With Peripartum Cardiomyopathy: A Qualitative Study.

Cardiovascular disease has been identified as the leading cause of maternal mortality in the United States, with cardiomyopathy, including peripartum cardiomyopathy (PPCM), accounting for 12% to 16% of all pregnancy-related deaths. The purpose of this study was to describe women's experiences being diagnosed with PPCM. This investigation was conducted using a qualitative design. We collected publicly available narratives posted by 92 women with PPCM (mean [SD] age 29 [6] years, mean [SD] ejection fraction 25.5 [10.8]%) in 3 online support groups. Data were coded and thematically organized so as to produce a richly detailed account of this experience. The experience of diagnosis was marked by the women's distinct memories of their initial symptoms and whether they were dismissed or taken seriously. The most commonly reported symptoms were extreme shortness of breath, orthopnea, tachycardia, palpitations, chest pain, cough, and edema. Nearly 40% of women experienced symptom dismissal by health care providers. One-fourth of women were initially given inaccurate diagnoses ranging from "new mom anxiety" to asthma. Women described their initial reaction to diagnosis as feeling terrified, devastated, and feeling a sense of doom. Women had difficulty caring for their newborns during the postpartum period, and they struggled with the medical advice they received to not get pregnant again. Despite experiencing severe subjective and objective symptoms, nearly 40% of women with PPCM experienced symptom dismissal by health care providers, in part due to the overlap between normal symptoms of pregnancy or the postpartum period and symptoms of heart failure.

Lifetime risk of pregnancy-related death among Zambian women: district-level estimates from the 2010 census

The aim of this study was to examine district differentials in the lifetime risk of pregnancy-related death among females aged 15–49 in Zambia. We used data on household deaths collected in the 2010 census to estimate the lifetime risk of pregnancy-related death among females in Zambia. Using all-cause age-specific death rates, we generated female life tables for 74 districts and estimated person-years of exposure to all-cause mortality at each age. We then applied age-specific pregnancy-related mortality rates to the person-years of exposure to obtain estimates of adult lifetime risk that took account of competing causes of death. We used the ArcGIS software to analyse clustering and the spatial distribution of risk. A female aged 15 in Zambia had a 3.7 % chance of dying a pregnancy-related death before the age of 50. At district level, the lifetime risk ranged from 1.7 to 7.7 %. The Global Moran’s I was 0.452 (z-score 5.8, p value <0.01), indicating clustering of districts with similar risk levels of pregnancy-related mortality. Clustering of high-risk districts was found in Western province while clustering of low risk districts was found in Lusaka and Muchinga provinces. The level of adult lifetime risk was more positively associated with pregnancy-related mortality than with fertility. Females in Zambia have a high lifetime risk of pregnancy-related death overall but this risk varies greatly across the different districts of the country. The observed diversity is larger than when merely studying differences between provinces and is only weakly linked to differences in fertility levels. The identification of districts with varying levels of risk should enable evidence-based and focused delivery of maternal health services in districts where risk of death from maternal causes is greatest.

Maternal Mortality From Hemorrhage in Michigan 1998–2011 [8

INTRODUCTION: Obstetric hemorrhage contributes significantly to the burden of maternal mortality. The objective of this study is to examine obstetric hemorrhage deaths in Michigan from 1998–2011 to determine etiology, preventability and modifiable/actionable factors that can be addressed to reduce hemorrhage mortality. METHODS: The records from all pregnancy-associated deaths from January 1, 1998 to December 31, 2011 were examined for the presence of disseminated intravascular coagulopathy, exsanguination, or hemorrhage. Cases were excluded when hemorrhage was not present, the cause of death was not from hemorrhage, or the death was not pregnancy-related. Extracted data included demographic information, details of the hospital course, and the final cause of death and the presence of preventability factors as determined by the State of Michigan Maternal Mortality review committee. RESULTS: Forty six cases of pregnancy related mortality from hemorrhage were identified. Postpartum hemorrhage (PPH) was the etiology with the greatest number of preventable deaths (7 of 12 total cases). Fifty percent of hemorrhage cases were considered to be preventable, 35% were considered to be not preventable, and 15% were not determined. In all cases where blood transfusion occurred, fresh frozen plasma transfusion was either absent or given at rates lower than currently recommended. CONCLUSION/IMPLICATIONS: Half of pregnancy related deaths from obstetric hemorrhage in Michigan were potentially preventable. Aggressive diagnosis and treatment of postpartum hemorrhage offers the best opportunity for prevention, and statewide educational programing to ensure proper administration of blood products is a necessary step to improving the quality of care and safety of childbirth.

Trends and Causes of Maternal Mortality at the Wa Regional Hospital, Ghana: 2005-2010

Maternal mortality has been a health concern for many developing countries. The study undertook a comprehensive maternal mortality audit at the Wa Regional Hospital in order to discover the trends and causes of maternal mortality at the hospital, and suggest ways of improving the situation. The study involved a retrospective examination of maternal mortality cases from January 1, 2005 to December 31, 2010. It included all pregnancy related deaths at the hospital within this period. A gynecologist and midwives served as key informants who provided primary data to augment the secondary data collected. Results showed a total of 73 maternal deaths occurred out of 14027 live births, giving a maternal mortality ratio of 520.4 per 100,000 live births. The yearly maternal mortality ratios saw an undulating scenario. On the specific causes of death, direct causes accounted for 60%, while indirect causes were 40%. Medically, haemorrhage (19%), Eclampsia (15%), Sepsis (11%), abortion related difficulties (8%) and obstructed labour (7%) were the main causes of mortality. Indirect causes include malaria, aneamia, sickle cell, HIV-Aids and TB. The trends of maternal mortality in the Upper West Regional Hospital over the period have seen a decline, but the decline is not significant enough. The number of women still dying from trying to bring life is unacceptably high. Key recommendations include the need to: improve emergency obstetric care by ensuring that there are enough personnel, logistics and facilities to attend to women who are in labour, especially 12 hours prior to delivery and after delivery.

Criteria-based audit of caesarean section in a referral hospital in rural Tanzania.

WHO uses the Caesarean section (CS) rate to monitor implementation of emergency obstetric care (EmOC). Although CS rates are rising in sub-Saharan Africa, maternal outcome has not improved. We audited indications for CS and related complications among women with severe maternal morbidity and mortality in a referral hospital in rural Tanzania. Cross-sectional study was from November 2009 to November 2011. Women with severe maternal morbidity and mortality were identified and those with CS were included in this audit. Audit criteria were developed based on the literature review and (inter)national guidelines. Tanzanian and Dutch doctors reviewed hospital notes. The main outcome measured was prevalence of substandard quality of care leading to unnecessary CS and delay in performing interventions to prevent CS. A total of 216 maternal near misses and 32 pregnancy-related deaths were identified, of which 82 (33.1%) had a CS. Indication for CS was in accordance with audit criteria for 36 of 82 (44.0%) cases without delay. In 20 of 82 (24.4%) cases, the indication was correct; however, there was significant delay in providing standard obstetric care. In 16 of 82 (19.5%) cases, the indication for CS was not in accordance with audit criteria. During office hours, CS was more often correctly indicated than outside office hours (60.0% vs. 36.0%, P < 0.05). Caesarean section rate is not an useful indicator to monitor quality of EmOC as a high rate of unnecessary and potentially preventable CS was identified in this audit.

Maternal mortality in Yazd Province, Iran.

IntroductionFive hundred thousand maternal deaths occur each year worldwide, many of which are in developing countries. The maternal mortality rate is a measure that demonstrates the degree of adequacy of prenatal care and of economic and social conditions. The aim of this study was to determine the frequency and causes of pregnancy-related mortality rates in Yazd Province.MethodsThis cross-sectional study examined the maternal deaths related to pregnancy that were recorded in Yazd Province, Iran, from 2002 to 2011. All maternal deaths that occurred during pregnancy, during delivery, and 42 days after birth were analyzed in this study. The data were collected through a questionnaire, and both direct and indirect causes of maternal deaths were determined.ResultsForty pregnancy-related deaths occurred in this period, and the maternal mortality rate was 20.8 deaths per 100,000 live births. The mean age of death in the mothers in this study was 29.17. Fifty-five percent of women of the women who died delivered their babies by cesarean section, and only 20% of them delivered their babies vaginally. Bleeding was the most common cause of maternal mortality (30%), and it was associated directly with maternal mortality. Furthermore 20% of the mothers died due to heart disease and cardiac complications, which were associated indirectly with maternal mortality.ConclusionCesarean section and its complications were the main cause of death in many cases. Thus, providing a strategic plan to reduce the use of this procedure, educate mothers, and ensure adequate access to pre-maternal care and to care during pregnancy are the most important measures that can be taken to decrease the maternal mortality rate.

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.