Heart disease No. 1 cause of pregnancy-related deaths in California

Heart disease is the leading cause of women’s pregnancy-related deaths in California - but nearly one-third could be prevented, according to research presented at the American Heart Association’s Scientific Sessions 2013.

Maternal death rates have been increasing in California and the United States since the mid-1990s, according to statistics from the California Department of Public Health.

“Women who give birth are usually young and in good health,” said Afshan B. Hameed, M.D., the study’s lead researcher and associate professor of clinical cardiology, obstetrics and gynecology at the University of California, Irvine. “So heart disease shouldn’t be the leading cause of pregnancy-related deaths, but it is.”

She said the results likely apply to the rest of the United States.

There were 2.1 million live births in California from 2002-2005.

Researchers analyzed medical records of 732 women who died from all causes while pregnant or within one year of pregnancy and found that:

  209 deaths were pregnancy-related.

  52 (about one quarter) of the pregnancy-related deaths were from some form of cardiovascular disease. Of note, only 6 percent had been diagnosed with a heart condition prior to the pregnancy.
  33 (or two-thirds) of the cardiovascular-related deaths were from cardiomyopathy - a serious disease in which the heart muscle is weakened and can lead to heart failure, irregular heartbeats, heart valve problems and death.

Maternal mortality – The global picture

HeaRt disease No. 1 cause of pregNancy-related deaths in California The death of a woman who leaves behind a young family has devastating consequences for these survivors, with increased chances of disadvantage, illness and premature death, especially in poorer societies. Maternal death (death during pregnancy or less than 42 days after the end of a pregnancy) is also the outcome measure that causes serious concern to public health authorities and maternity care clinicians. No health outcome shows such large discrepancies between rich and poor nations. The most recent reliable figures show more than hundred-fold differences in maternal mortality ratios (MMR – deaths per 100 000 live births). For example, for 2008 the MMRs in Italy, Egypt, South Africa, Zimbabwe, Lesotho, and Afghanistan were estimated at 4, 43, 237, 624, 964 and 1595 respectively. The Millennium Development Goal (MDG) 5a has as its target the reduction of maternal mortality by 75% from 1990 to 2015. A number of middle-income countries have made good progress, and Egypt, for example, has already attained its MDG 5a goal. South Africa, also a middle-income country, has unfortunately seen an increase in maternal mortality, related mainly to deaths caused by HIV and AIDS. Given the 1990 figure from this source, South Africa needs to reduce its MMR to 30 by 2015, clearly an unattainable goal at present. Progress towards MDG 5a is also not good in other African countries south of the Sahara, although recent small reductions from very high levels of mortality have been shown.

Worldwide, it is estimated that there were 342 900 maternal deaths in 2008, with the major contributors being South Asia, and Africa south of the Sahara. Classically, the ‘big 3’ causes of maternal death are obstetric haemorrhage, hypertension and pregnancy-related sepsis. In poorer countries, this reflects deficiencies in infrastructure, health services and skilled attendance at childbirth. A large proportion of cases of haemorrhage and sepsis result from unattended obstructed labour. Furthermore, illegally induced abortions result in thousands of deaths from haemorrhage and sepsis, and go almost unnoticed in countries where safe abortion services are not available. The World Health Organization’s World Health Report of 2005, dedicated to maternal and infant health, made a plea for countries to invest politically, socially and financially in human resources, health facilities and institutional capacity, to achieve universal health care coverage and reduce this burden of unnecessary and preventable mortality.

Compared to women who died of non-heart-related causes, researchers found that:

  Women who were most likely to die from pregnancy-related heart disease were African-American, obese or had documented substance abuse during pregnancy.
  Nearly one-fourth of the women who died of cardiac causes had been diagnosed with high blood pressure during their pregnancies.

In about two-thirds of the deaths, the diagnosis was either incorrect or delayed, or providers had given ineffective or inappropriate treatments, researchers said.  One third of the patients who died had delayed or failed to seek care, 10 percent refused medical advice and 27 percent did not recognize their symptoms as cardiovascular.

Child Health USA 2012 - Pregnancy-Related Mortality

HeaRt disease No. 1 cause of pregNancy-related deaths in California A pregnancy-related death is defined as a death which occurs during or within one year after the end of a pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes such as injury. This definition includes more deaths than the traditional definition of maternal mortality, which counts pregnancy-related deaths only up to 42 days after the end of pregnancy. Although maternal mortality in the United States declined dramatically over the last century, this trend has reversed somewhat in the last several decades, and racial and ethnic disparities in both maternal and pregnancy-related mortality persist.

In 2006-2007, the latest years for which data are available, a total of 1,294 deaths were found to be pregnancy-related (15.1 deaths per 100,000 live births). This represents a substantial increase from 1987 levels of 7.2 pregnancy-related deaths per 100,000 live births. However, the extent to which this increase may reflect improved identification and coding of pregnancy-related deaths is unclear. The pregnancy-related mortality ratio among Black women was approximately 3.2 times the rate for White women in 2006-2007 (34.8 versus 11.0 per 100,000), a disparity that has remained relatively constant. The pregnancy-related mortality ratio also increased with age. Women aged 35-39 years were more than twice as likely to die from pregnancy-related causes as women aged 20-24; for women older than 39 years, the risk increased five-fold (data not shown in graph images or in data tables on this site).

Some of the most common causes of pregnancy- related death in 2006-2007 were cardiovascular disease (13.5%), diseases of the heart muscle (cardiomyopathy, 12.6%), uncontrolled bleeding (hemorrhage, 11.9%), and non-cardiovascular medical conditions (11.8%). In 1987-1990, hemorrhage was the leading cause of pregnancy-related deaths (29%); hypertensive disorders of pregnancy, including preeclampsia and eclampsia, accounted for almost 18 percent of pregnancy-related deaths, compared to 11.1 percent in 2006-2007.

“Women should attain and maintain proper weight before and during pregnancy, and talk to their doctors if they have personal or family histories of heart disease,” Hameed said. “And healthcare providers should be referring pregnant women who complain of symptoms consistent with cardiac disease to specialists, especially when these risk factors are present. Women with evidence of substance abuse should receive early referral for treatment.”

But, Hameed noted, it is impossible to know if earlier diagnosis and intervention would have prevented death in these cases “as missed cues to the presence of heart disease were common.”

Co-authors are Elyse Foster, M.D.; Christy McCain, M.P.H.; Christine Morton, Ph.D.; and Elliott Main, M.D. Author disclosures are on the abstract.

The California Department of Public Health, Maternal Child and Adolescent Health funded the study.

Note: Actual presentation is 9:30 a.m. CT/10:30 a.m. ET Sunday, Nov. 17, 2013.

Learn more information about heart disease prevention guidelines for women.

Downloadable video/audio interviews, B-roll, animation and images related to this news release are on the right column of the release link at http://url.health.am/1320/

Video clips with researchers/authors of the studies will be added to the release link after embargo.

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Statements and conclusions of study authors that are presented at American Heart Association scientific meetings are solely those of the study authors and do not necessarily reflect association policy or position. The association makes no representation or warranty as to their accuracy or reliability. The association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific association programs and events. The association has strict policies to prevent these relationships from influencing the science content.


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