Maternal mortality in Utah

Standardized Criteria for Review of Perinatal Suicides and Accidental Drug-Related Deaths

OBJECTIVE

To estimate the proportion of accidental drug-related deaths and suicides classified as pregnancy-related from 2013 to 2014 (preimplementation of standardized criteria) and 2015 to 2016 (postimplementation).

METHODS

Based on Centers for Disease Control and Prevention pregnancy-related death criteria, the Utah Perinatal Mortality Review Committee developed a standardized evaluation tool to assess accidental drug-related death and suicide beginning in 2015. We performed a retrospective case review of all pregnancy-associated deaths (those occurring during pregnancy or 1 year postpartum for any reason) and pregnancy-related deaths (those directly attributable to the pregnancy or postpartum events) evaluated by Utah's Perinatal Mortality Review Committee from 2013 to 2016. We compared the proportion of accidental drug-related deaths and suicides meeting pregnancy-related criteria preimplementation and postimplementation of a standardized criteria checklist tool using Fisher's exact test. We assessed the change in pregnancy-related mortality ratio in Utah from 2013 to 2014 and 2015 to 2016 using test of trend.

RESULTS

From 2013 to 2016, there were 80 pregnancy-associated deaths in Utah (2013-2014: n=40; 2015-2016: n=40), and 41 (51%) were pregnancy-related (2013-2014: n=15, 2015-2016: n=26). In 2013-2014 (preimplementation), 12 women died of drug-related deaths or suicides, and only two of these deaths were deemed pregnancy-related (17%). In 2015-2016 (postimplementation), 18 women died of drug-related deaths or suicide, and 94% (n=17/18) of these deaths met one or more of the pregnancy-related criteria on the checklist (P<.001). From 2013 to 2014 to 2015-2016, Utah's overall pregnancy-related mortality ratio more than doubled, from 11.8 of 100,000 to 25.7 of 100,000 (P=.08).

CONCLUSION

After application of standardized criteria, the Utah Perinatal Mortality Review Committee determined that pregnancy itself was the inciting event leading to the majority of accidental drug-related deaths or suicides among pregnant and postpartum women. Other maternal mortality review committees may consider a standardized approach to assessing perinatal suicides and accidental drug-related deaths.

Perinatal implications of motor vehicle accident trauma during pregnancy: identifying populations at risk

OBJECTIVE

The purpose of this study was to examine the association between restraint use, race, and perinatal outcome after motor vehicle accidents (MVAs) during pregnancy.

STUDY DESIGN

The Duke Trauma Registry and medical records were searched for information on pregnant women at >14 weeks' gestation who were involved in an MVA and who received care through the Emergency Department and the Obstetric Units. Between January 1994 and December 31, 2010, 126 women were identified. Variables that were collected included type of trauma, gestational age at presentation, and delivery outcomes. A prognostic study was performed that evaluated the associations between maternal demographics, details of the accident that included restraint use, and maternal treatment that was related to the accident in relationship to perinatal outcome.

RESULTS

There was no difference in the mean age or median gravidity or parity by race among pregnant women who were cared for after an MVA. There was no difference in mean age or racial distribution between women who were restrained compared with women who were unrestrained; unrestrained women were more likely to be nulliparous. Unrestrained women were more likely to require nonobstetric surgery that was related to the trauma. The overall rate of placental abruption was 6%. There were 6 intrauterine fetal deaths, 3 each in the unrestrained (25%) and restrained groups (3.5%; P = .018). Airbags deployed in 17 accidents. Among the 7 women with placenta abruption, 4 women (57%) experienced air bag deployment.

CONCLUSION

Lack of restraint use during pregnancy is associated with an increased risk of fetal death.

Quality indicators for continuous monitoring to improve maternal and infant health in maternity departments: a modified Delphi survey of an international multidisciplinary panel

OBJECTIVE

Measuring the quality of inpatient obstetrical care using quality indicators is becoming increasingly important for both patients and healthcare providers. However, there is no consensus about which measures are optimal. We describe a modified Delphi method to identify a set of indicators for continuously monitoring the quality of maternity care by healthcare professionals.

METHODOLOGY AND MAIN FINDINGS

An international French-speaking multidisciplinary panel comprising 22 obstetricians-gynaecologists, 12 midwives, and 1 paediatrician assessed potential indicators extracted from a medical literature search, using a two-round Delphi procedure followed by a physical meeting. Each panellist rated each indicator based on validity and feasibility. In the first round, 35 panellists from 5 countries and 20 maternity units evaluated 26 indicators including 15 related to the management of the overall population of pregnant women, 3 to the management of women followed from the first trimester of pregnancy, 2 to the management of low-risk pregnant women, and 6 to the management of neonates. 25 quality indicators were kept for next step. In the second round, 27 (27/35: 77%) panellists selected 17 indicators; the remaining 8 indicators were discussed during a physical meeting. The final set comprised 18 indicators.

CONCLUSION

A multidisciplinary panel selected indicators that reflect the quality of obstetrical care. This set of indicators could be used to assess and monitor obstetrical care, with the goal of improving the quality of care in maternity units.

Measuring the quality of inpatient obstetrical care

Obstetric admissions are the leading cause of hospitalization for women in the United States, accounting for over 4 million hospital discharges each year. Measuring the quality of inpatient obstetrical care provided to these women is becoming increasingly important to patients, providers, and insurers. While numerous quality measures have been proposed, there is no agreement as to which measures should be used. An ideal quality measure for inpatient obstetrics would encompass 5 major characteristics: 1) association with meaningful maternal and neonatal outcomes, 2) relation to outcomes that are influenced by physician/health system behaviors, 3) affordability for application on a large scale basis, 4) acceptability to practicing obstetricians as a meaningful marker of quality, and 5) reliability/reproducibility. Traditional quality measurement tools such as maternal mortality, neonatal mortality and cesarean delivery rate are flawed measures. New measurements such as risk-adjusted primary cesarean rates, the nulliparous term singleton vertex cesarean birth (NTSV) rate, and the Adverse Outcomes Index (AOI) are currently being studied but these measures require further validation before widespread adoption.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader should be able to summarize that quality measures of inpatient obstetrical care are numerous, explain that no one agrees on which measures should be used, and state that newer measures, once validated, should be considered.

Pulmonary embolism during and after pregnancy

BACKGROUND

Venous thromboembolic disease is among the most common causes of morbidity and mortality during pregnancy. The clinical evaluation alone is insufficient for the diagnosis of venous thromboembolic disease, and the normal pregnant state makes this evaluation even more challenging.

DIAGNOSIS

Objective testing is the mainstay of diagnosis, including compression ultrasound, impedance plethysmography, ventilation-perfusion scanning, computed tomography scanning, and pulmonary angiography. All of these tests can be safety performed during pregnancy.

TREATMENT

If deep vein thrombosis or pulmonary embolism is diagnosed, anticoagulation should be initiated. Either (unfractionated) heparin or low molecular weight heparin is an acceptable treatment for acute venous thromboembolic disease. Both have risks and benefits, but both can be used safely during pregnancy. Intravenous heparin is the treatment of choice surrounding delivery due to its short half life. Because of the risk of adverse effects on the fetus, warfarin is not generally used during pregnancy. Unstable pulmonary embolism is difficult to treat during pregnancy, as there are minimal data regarding the safety and efficacy of thrombolytic therapy, inferior vena cava filters, and embolectomy during pregnancy. Case reports and case series suggest that thrombolytic therapy may be associated with lower risks of fetal loss than embolectomy.

CONCLUSIONS

Venous thromboembolic disease is a significant cause of morbidity and mortality during pregnancy and the puerperal period. Objective testing is critical to establish the diagnosis and can be safely performed during pregnancy. Anticoagulation with heparin is the mainstay of therapy during the pregnancy, but patients may be transitioned to warfarin after delivery.

Preventability of pregnancy-related deaths: results of a state-wide review

OBJECTIVE

Although the risk of death from complications of pregnancy in the 20th century has decreased dramatically, several lines of evidence suggest that it has not reached an irreducible minimum. To further reduce pregnancy-related mortality, we must understand which deaths are potentially preventable and the changes needed to prevent them. We sought to identify all pregnancy-related deaths in North Carolina and conduct a comprehensive review examining ways in which the number of these deaths could potentially be reduced.

METHODS

The North Carolina Pregnancy-Related Mortality Review Committee reviewed all of the 108 pregnancy-related deaths (women who died during or within 1 year of the end of pregnancy from a complication of pregnancy or its treatment) that occurred in the state in 1995-1999. For each death, the committee determined the cause of death, whether it could have been prevented, and if so, the means by which it might have been prevented.

RESULTS

Although overall, 40% of pregnancy-related deaths were potentially preventable, this varied by the cause of death. Almost all deaths due to hemorrhage and complications of chronic diseases were believed to be potentially preventable, whereas none of the deaths due to amniotic fluid embolus, microangiopathic hemolytic syndrome, and cerebrovascular accident were considered preventable. Improved quality of medical care was considered to be the most important factor in preventing these deaths. Among African-American women, 46% of deaths were potentially preventable, compared with 33% of the deaths among white women.

CONCLUSION

Despite the decline in pregnancy-related mortality rates, almost one half of these deaths could potentially be prevented, mainly through improved quality of medical care. In-depth review of pregnancy-related deaths can help determine strategies needed to continue making pregnancy safer.

Pulmonary embolism and pregnancy

Pulmonary embolism is a significant cause of morbidity and mortality during pregnancy and the puerperium. The spectrum of venous thromboembolism is difficult to diagnose. Objective diagnostic testing is crucial and should not be delayed. Anticoagulation is the mainstay of therapy for deep vein thrombosis and pulmonary embolism. Most of the literature and practice protocols for the treatment of pregnant women are based on data extrapolated from the nonpregnant population, and more research is needed to improve the understanding of the efficacy and safety of testing and therapy in the pregnant population.

Maternal mortality--a review of current trends

Pregnancy-related maternal deaths, although rare,are higher than the public health goal of no more than 3 per 100000 live births [5,6]. Achievement of this goal mandates complete and consistent reporting of all maternal deaths to identify causes of death accurately and correct underreporting [2]. Racial disparity between white and African American women must be reduced. Further research is needed to identify the factors contributing to the higher mortality rates in the African American population. Risk factors currently identified with adverse perinatal outcomes do not explain the differences in mortality rates adequately. Perinatal nurses and primary care providers should take an active role in identifying current trends in causes of matemal mortality. The population of women encountered daily in perinatal units is changing, with an increasing number of pregnancies complicated by preexisting and pregnancy-related medical conditions. Caring for these women within the framework that pregnancy is a normal, physiologic state can lead to complacency and increase the probability of missing early signs of maternal decompensation from an undiagnosed cardiac lesion, because shortness of breath and decreased exercise tolerance are considered normal changes as the pregnancy advances. Common complaints of pregnancy often mimic early signs of cardiopulmonary compromise, delaying an accurate diagnosis. The perinatal nurse must be aware of the early signs of an impending cardiopulmonary arrest. If recognized. subtle changes in levels of mentation, increasing pulse and respiratory rates, and changes in blood pressure lead to earlier interventions to correct maternal hemodynamic status and possibly prevent cardiopulmonary collapse. To further complicate the issue, the mindset in perinatal units often is, "It can't happen here" or "We don't have codes in obstetrics."Perinatal units should practice emergency drills, including management of eclampsia, hemorrhage, and cardiopulmonary arrest. Rehearsal of the emergency situation helps decrease anxiety for the staff and increase response times. The goal of the irreducible minimum for prevent-able maternal deaths is one to strive for in today's perinatal practice. Active surveillance to identify causes of maternal mortality allows for initiation of early interventions to minimize maternal compromise, thereby decreasing preventable deaths.

Racial disparity in pregnancy-related mortality following a live birth outcome

PURPOSE

African-American women have a 2- to 4-fold increased risk of pregnancy-related death compared with Caucasian women. We conducted this study to determine if differences in a combination of socioeconomic and medical risk factors may explain this racial disparity in pregnancy-related death.

METHODS

Pregnancy-related deaths of African-American (N=60) and Caucasian (N=47) women were identified from review of pregnancy-associated deaths (N=400) ascertained through cause of death on death certificates, electronic linkage of birth and death files, and review of the hospital discharge database for the State of North Carolina, during the period between 1992 and 1998. Controls (N=3404) were randomly selected from all live births for the same 7-year period. Logistic regression was used to model the association between race and pregnancy-related death.

RESULTS

The unadjusted odds ratio (OR) for pregnancy-related death for African-Americans compared with Caucasians was 3.07 (95% confidence interval [CI], 2.08, 4.54). After controlling for gestational age at delivery, maternal age, income, hypertension, and receipt of prenatal care, African-American race remained a significant predictor variable (OR 2.65 [95% CI 1.73, 4.07]).

CONCLUSIONS

Our analysis confirms that there is a strong association between race and pregnancy-related death, even after adjusting for potential predictors and confounders.

Amniotic fluid embolism with involvement of the brain, lungs, adrenal glands, and heart

The case of a healthy 31-year-old woman in the 40th week of second pregnancy is presented. During preparation for an emergency caesarean section, she developed an amniotic fluid embolism (AFE) with unusual and unique features. The acute onset of disease with cardiorespiratory failure with hypotension, tachycardia, cyanosis, respiratory disturbances and loss of consciousness, suggested at first a pulmonary thromboembolism, but the appearance of convulsions led to the diagnosis of AFE. The patient died after 5 days due to an untreatable brain edema. At autopsy, AFE with the usually associated disseminated intravascular coagulation was found in the lungs, brain, left adrenal gland, kidneys, liver and heart. Eosinophilic inflammatory infiltrates were found in the lungs, hepatic portal fields and especially in the heart, suggesting a specific hypersensitivity reaction to fetal antigens. Moreover, intravascular accumulation of macrophages in the lungs also favored a non-specific immune reaction to amniotic fluid constituents.

Car seatbelt use during pregnancy in Japan: determinants and policy implications

CONTEXT

Pregnant women are exempted from the current seatbelt legislation in Japan despite the fact that seatbelt use is essential to reduce the risk of fatalities for these women and their fetuses in car crashes.

OBJECTIVE

To examine factors that might influence seatbelt use during pregnancy.

METHODS

A cross sectional study, with data collected via an anonymous, self administered questionnaire at obstetric clinics in suburban areas of Japan. Altogether 880 pregnant women receiving prenatal care in July 2001 were recruited. The relative effects of factors that might influence seatbelt use during pregnancy were estimated using logistic regression analysis.

RESULTS

Almost 70%-80% of pregnant women were consistent seatbelt wearers before pregnancy but seatbelt compliance was reduced by about half at 20 weeks or more gestation. Only 20% had received information on maternal seatbelt use, with one third reporting that seatbelt use is beneficial during pregnancy. Those who perceived that maternal seatbelt use is beneficial tended to maintain use, but daily car users and those who knew that they were exempted from seatbelt legislation were more likely to reduce use.

CONCLUSIONS

Knowledge of the legislative exemption for pregnant women, misunderstanding of the benefits, and daily car use contributed to the reduction in seatbelt use after pregnancy.

Maternal mortality in Greece (1980-1996)

OBJECTIVE

To use data from the National Statistical Service of Greece to examine trends in maternal mortality and risk factors for maternal deaths.

STUDY DESIGN

Maternal mortality in Greece has been studied from years 1980 to 1996 in total, by cause of death, by residency (urban/rural) and by maternal age. The maternal mortality ratio (MMR) has been defined as the number of deaths per 100,000 live births.

RESULTS

From years 1980 to 1996, there have been 136 maternal deaths (MMR: 7). The number of deaths has significantly decreased during this period and six major causes of death have been identified, resulting in 80% of maternal deaths. A simulation of maternal mortality between urban and rural areas has been achieved during the last decade. Also, maternal mortality rises dramatically with age.

CONCLUSIONS

Although overall rates of maternal mortality in Greece have been significantly decreased over the last years, an improved recording of maternal deaths is necessary for identifying preventable factors and developing effective interventions.

Maternal mortality during hospital admission for delivery: a retrospective analysis using a state-maintained database

This study reports the overall age- and race-specific delivery mortality ratios from January 1984 to December 1997 and medical and demographic risk factors associated with maternal death during hospital admission for delivery. We performed a retrospective case control study using patient records from a state-maintained anonymous database of all nonfederal Maryland hospitals that performed deliveries from 1984 to 1997. Variables studied included patient demographics and International Classification of Diseases, 9th Revision, Clinical Modification, diagnosis, and procedure codes. Mortality was the outcome variable. Of the 822,591 hospital admissions for delivery during the 14-yr study period, there were 135 deaths. The overall delivery mortality ratio was 16.4. The most common diagnoses associated with mortality during hospital admission for delivery included preeclampsia/eclampsia (22.2%), postpartum hemorrhage/obstetric shock (22.2%), pulmonary complications (14%), blood clot and/or amniotic embolism (8.1%), and anesthesia-related complications (5.2%). The identification of medical and demographic risk factors may have significant implications creating initiatives aimed at decreasing the public health burden associated with maternal mortality.

IMPLICATIONS

This study reports the medical and demographic risk factors associated with maternal death during hospital admission for delivery by using a state-maintained database. This information could prove useful in the creation of initiatives aimed at decreasing the public health burden associated with maternal mortality.

Trophoblastic microemboli as a marker for preeclampsia-eclampsia in sudden unexpected maternal death: a case report and review of the literature

The authors report the case of a 25-year-old white woman at 7 months' gestation who died suddenly and unexpectedly at home. Anatomic findings at autopsy included a tongue contusion, glomerulonephritis, changes indicative of systemic hypertension, and trophoblastic microemboli in the lungs. Review of the prenatal care record disclosed 3+ proteinuria 2 days before death. The features of the postmortem examination were consistent with clinically undiagnosed preeclampsia-eclampsia and glomerulonephritis. The authors discuss the rarity of fatal preeclampsia-eclampsia, the contribution of concomitant glomerulonephritis, and the significance of trophoblastic microemboli in the lungs.

Maternal deaths in an urban perinatal network, 1992-1998

OBJECTIVE

The object of this study was to use an in-depth peer-review process to determine the maternal mortality ratio at a single urban perinatal center and to identify factors associated with fatal outcomes to elucidate opportunities for preventive measures to reduce the maternal mortality ratio.

STUDY DESIGN

Between 1992 and 1998 all maternal deaths occurring within our perinatal network were identified. A peer-review committee was established to review all available data for each death to determine the underlying cause of death, whether it was related to pregnancy, and whether the death was potentially preventable.

RESULTS

There were 131,500 births and 42 maternal deaths, for a maternal mortality ratio of 31.9 maternal deaths per 100,000 live births. The adjusted pregnancy-related maternal mortality ratio was 22.8 maternal deaths per 100,000 live births, with 37% of those deaths (11/30) deemed potentially preventable and a provider factor cited in >80% of these. Pulmonary embolus and cardiac disease together accounted for 40% of the pregnancy-related deaths.

CONCLUSION

Local maternal mortality ratios identified through a peer-review process indicate that the magnitude of the problem is much greater than is recognized through national death certificate data. The high proportion of potentially preventable maternal deaths indicates the need for improvement in both patient and provider education if we are to reduce the maternal mortality ratio to 3.3 maternal deaths per 100,000 live births, the stated national health goal of Healthy People 2000.

A null mutation in HLA-G is not associated with preeclampsia or intrauterine growth retardation

Modulation of the expression of genes of the major histocompatibility complex (MHC) in tissues at the maternal-fetal interface almost certainly plays a role in successful development of the semi-allogeneic fetus. While expression of the classical class I genes (HLA-A, B, C) is low to non-existent at this site, the non-classical molecule, HLA-G, is expressed uniquely in fetal cells at the maternal-fetal interface. The recent demonstration that homozygotes for a deletion mutation in exon 3 (1597DeltaC) of HLA-G do not express the full-length HLA-G1 isoforms indicates a potential reduction in expression of this isoform in heterozygotes. If the full-length isoform of HLA-G (i.e. HLA-G1) contributes to proper invasion of maternal spiral arteries by extravillous cytotrophoblast, then 1597DeltaC heterozygotes could be at increased risk for disorders of trophoblast invasion. Two populations, infants with intrauterine growth retardation (IUGR) and infants of preeclamptic (PE) mothers, were genotyped for the 1597DeltaC polymorphism. The frequency of 1597DeltaC in these samples was not significantly different from healthy controls, suggesting that heterozygotes for this deletion mutation are not at significantly increased risk for PE or IUGR (P = 0.727 and 0.803, respectively).