Comparison of severe maternal morbidity in pregnancy by modified World Health Organization Classification of maternal cardiovascular risk.
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ABSTRACT: Background
To compare rates of severe maternal morbidity (SMM) for pregnant patients with a cardiac diagnosis classified by the modified World Health Organization (mWHO) classification to those without a cardiac diagnosis.Methods
This retrospective study using the 2015-2019 Nationwide Readmissions Database identified hospitalizations, comorbidities, and outcomes using diagnosis and procedure codes. The primary exposure was cardiac diagnosis, classified into low-risk (mWHO class I and II) and moderate-to-high-risk (mWHO class II/III, III, or IV). The primary outcome was SMM or death during the delivery hospitalization; secondary outcomes included cardiac-specific SMM during delivery hospitalizations and readmissions after the delivery hospitalization.Results
A weighted national estimate of 14,995,122 delivery admissions was identified, including 46,541 (0.31%) with mWHO I-II diagnoses and 37,330 (0.25%) with mWHO II/III-IV diagnoses. Patients with mWHO II/III-IV diagnoses experienced SMM at the highest rates (22.8% vs 1.6% for no diagnosis; with adjusted relative risk (aRR) of 5.67 [95% CI: 5.36-6.00]). The risk of death was also highest for patients with mWHO II/III-IV diagnoses (0.3% vs <0.1% for no diagnosis; aRR 18.07 [95% CI: 12.25-26.66]). Elevated risk of SMM and death persisted to 11 months postpartum for those patients with mWHO II/III-IV diagnoses.Conclusions
In this nationwide database, SMM is highest among individuals with moderate-to-severe cardiac disease based on mWHO classification. This risk persists in the year postpartum. These results can be used to enhance pregnancy counseling.
SUBMITTER: Denoble AE
PROVIDER: S-EPMC9836743 | biostudies-literature | 2022 Aug
REPOSITORIES: biostudies-literature
Publications
Comparison of severe maternal morbidity in pregnancy by modified World Health Organization Classification of maternal cardiovascular risk.
Denoble Anna E AE Goldstein Sarah A SA Wein Lauren E LE Grotegut Chad A CA Federspiel Jerome J JJ
American heart journal 20220505
<h4>Background</h4>To compare rates of severe maternal morbidity (SMM) for pregnant patients with a cardiac diagnosis classified by the modified World Health Organization (mWHO) classification to those without a cardiac diagnosis.<h4>Methods</h4>This retrospective study using the 2015-2019 Nationwide Readmissions Database identified hospitalizations, comorbidities, and outcomes using diagnosis and procedure codes. The primary exposure was cardiac diagnosis, classified into low-risk (mWHO class I ...[more]
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Project description:BackgroundCardiac disease is a leading cause of maternal morbidity and mortality in the United States, and an increasing number of patients with known cardiac disease are reaching childbearing age. Although guidelines indicate that cesarean deliveries should be reserved for obstetrical indications, rates of cesarean delivery among obstetrical patients with cardiovascular disease are higher than those of the general population.ObjectiveThis study aimed to evaluate mode of delivery and perinatal outcomes among patients with low-risk and moderate to high-risk cardiac disease as defined by the modified World Health Organization classification of maternal cardiovascular risk.Study designWe performed a retrospective cohort study of obstetrical patients with known cardiac disease, as defined by the modified World Health Organization cardiovascular classification categories in pregnancy, who underwent a perinatal transthoracic echocardiogram at a single academic medical center between October 1, 2017 and May 1, 2022. Demographics, clinical characteristics, and perinatal outcomes were collected. Comparisons were made between patients with low- (modified World Health Organization Class I) and moderate to high-risk (modified World Health Organization Class II-IV) cardiac disease using chi-square, Fisher exact, or Student t-tests. Cohen d tests were used to estimate the effect size between group means. Logistic regression models were used to evaluate the odds of vaginal and cesarean delivery in low- and moderate to high-risk groups.ResultsA total of 108 participants were eligible for inclusion, with 41 participants in the low-risk cardiac group and 67 in the moderate to high-risk group. Participants had a mean age of 32.1 (±5.5) years at the time of delivery and a mean pregravid body mass index of 29.9 (±7.8) kg/m2. Chronic hypertension (13.9%) and a history of hypertensive disorder of pregnancy (14.9%) were the most common comorbid medical conditions. In total, 17.1% of the sample had a history of a cardiac event (eg, arrhythmia, heart failure, myocardial infarction). Rates of vaginal and cesarean deliveries were similar between the low- and moderate to high-risk cardiac groups. Patients in the moderate to high-risk cardiac group were more likely to be admitted to the intensive care unit during pregnancy (odds ratio, 7.8; P<.05) and experience severe maternal morbidity compared with patients in the low-risk cardiac group (P<.01). Mode of delivery was not associated with severe maternal morbidity in the higher-risk cardiac group (odds ratio, 3.2; P=.12). In addition, infants of mothers with higher-risk disease were more likely to be admitted to the neonatal intensive care unit (odds ratio, 3.6; P=.06) and have longer neonatal intensive care unit stays (P=.005).ConclusionThere was no difference in mode of delivery by modified World Health Organization cardiac classification, and mode of delivery was not associated with risk of severe maternal morbidity. Despite the overall increased risk of morbidity in the higher-risk group, vaginal delivery should be considered as an option for certain patients with well-compensated cardiac disease. However, larger studies are needed to confirm these findings.
| S-EPMC11577448 | biostudies-literature
Project description:ImportancePregnant individuals who repeatedly use emergency care during pregnancy represent a population who could be disproportionately vulnerable to harm, including severe maternal morbidity (SMM).ObjectiveTo explore patterns of unscheduled care visits during pregnancy and ascertain its association with SMM at the time of birth.Design, setting, and participantsThis cohort study used data from a statewide database that linked hospital records to births and fetal deaths occurring between October 1, 2002, and March 31, 2020, in Massachusetts. Pregnant individuals experiencing births or fetal deaths during the study period were included. Data analysis was conducted from June 2022 to September 2024.ExposureThe exposure was 4 or more cases of emergency use, defined as either an emergency department visit or observational stay during pregnancy not resulting in hospital admission. Pregnancy episode was ascertained by subtracting the gestational age at birth from the date of birth.Main outcomes and measuresThe outcome of interest was the odds ratio (OR) for SMM at the time of birth. The algorithm includes 20 conditions or procedures (excluding transfusion) identified through International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes across the study period.ResultsA total of 774 092 pregnant individuals (mean [SD] age, 31.2 [5.8] years; 16.8% Hispanic, 9.3% non-Hispanic Asian or Pacific Islander, 9.5% non-Hispanic Black, 63.1% non-Hispanic White) with emergency care visits during the pregnancy were included; 31.3% of these individuals had at least 1 visit. Overall, 18.1% had 1 visit and 3.3% had 4 or more visits. Four or more unscheduled visits were common among those younger than age 25 years (8.7%), with Hispanic (5.7%) or non-Hispanic Black (4.9%) race and ethnicity, with public insurance (6.5%), or with a comorbidity (19.0%) or an opioid use-related hospitalization (26.8%) in the year prior to pregnancy. Of those with 4 or more unscheduled visits, 43.8% visited more than 1 hospital during pregnancy. In a multivariable analysis of the likelihood of SMM, those with 4 or more unscheduled visits had an adjusted OR of 1.46 (95% CI, 1.29-1.66) compared with those with 0 visits.Conclusions and relevanceThis cohort study found that high emergency care use during pregnancy was associated with an increased risk for SMM. With a significant proportion of those with frequent unscheduled visits also using multiple hospitals, solutions that are community-based and integrated across health systems may be most beneficial.
| S-EPMC11581629 | biostudies-literature
Project description:ImportanceThe rate of severe maternal morbidity (SMM) is continuously increasing in the US. Evidence regarding the associations of climate-related exposure, such as environmental heat, with SMM is lacking.ObjectiveTo examine associations between long- and short-term maternal heat exposure and SMM.Design, setting, and participantsThis retrospective population-based epidemiological cohort study took place at a large integrated health care organization, Kaiser Permanente Southern California, between January 1, 2008, and December 31, 2018. Data were analyzed from February to April 2023. Singleton pregnancies with data on SMM diagnosis status were included.ExposuresModerate, high, and extreme heat days, defined as daily maximum temperatures exceeding the 75th, 90th, and 95th percentiles of the time series data from May through September 2007 to 2018 in Southern California, respectively. Long-term exposures were measured by the proportions of different heat days during pregnancy and by trimester. Short-term exposures were represented by binary variables of heatwaves with 9 different definitions (combining percentile thresholds with 3 durations; ie, ≥2, ≥3, and ≥4 consecutive days) during the last gestational week.Main outcomes and measuresThe primary outcome was SMM during delivery hospitalization, measured by 20 subconditions excluding blood transfusion. Discrete-time logistic regression was used to estimate associations with long- and short-term heat exposure. Effect modification by maternal characteristics and green space exposure was examined using interaction terms.ResultsThere were 3446 SMM cases (0.9%) among 403 602 pregnancies (mean [SD] age, 30.3 [5.7] years). Significant associations were observed with long-term heat exposure during pregnancy and during the third trimester. High exposure (≥80th percentile of the proportions) to extreme heat days during pregnancy and during the third trimester were associated with a 27% (95% CI, 17%-37%; P < .001) and 28% (95% CI, 17%-41%; P < .001) increase in risk of SMM, respectively. Elevated SMM risks were significantly associated with short-term heatwave exposure under all heatwave definitions. The magnitude of associations generally increased from the least severe (HWD1: daily maximum temperature >75th percentile lasting for ≥2 days; odds ratio [OR], 1.32; 95% CI, 1.17-1.48; P < .001) to the most severe heatwave exposure (HWD9: daily maximum temperature >95th percentile lasting for ≥4 days; OR, 2.39; 95% CI, 1.62-3.54; P < .001). Greater associations were observed among mothers with lower educational attainment (OR for high exposure to extreme heat days during pregnancy, 1.43; 95% CI, 1.26-1.63; P < .001) or whose pregnancies started in the cold season (November through April; OR, 1.37; 95% CI, 1.24-1.53; P < .001).Conclusions and relevanceIn this retrospective cohort study, long- and short-term heat exposure during pregnancy was associated with higher risk of SMM. These results might have important implications for SMM prevention, particularly in a changing climate.
| S-EPMC10485728 | biostudies-literature
Project description:Severe maternal morbidity (SMM) is a composite outcome measure that indicates serious, potentially life-threatening maternal health problems. There is great interest in defining SMM using administrative data for surveillance and research. In the United States, one common way of defining SMM at the population level is an index developed by the Centers for Disease Control and Prevention. Modifications to this index (e.g., exclusion of maternal blood transfusion) have been proposed; some research defines SMM using an index introduced by Bateman et al. (Obstet Gynecol. 2013;122(5):957-965). Birth certificate data are also increasingly being used to define SMM. We compared commonly used US definitions of SMM among all California births (2007-2012) using the kappa (κ) statistic and other measures. We also evaluated agreement between maternal morbidity fields on the birth certificate as compared with health insurance claims data. Concordance between the 7 definitions of SMM analyzed was generally low (i.e., κ < 0.41 for 13 of 21 two-way comparisons). Low concordance was particularly driven by the presence/absence of transfusion and claims data versus birth certificate definitions. Low agreement between administrative data-based definitions of SMM highlights that results can be expected to differ between them. Further research on validity of SMM definitions, using more fine-grained data sources, is needed.
| S-EPMC8579027 | biostudies-literature
Project description:ImportanceThe incidence of severe maternal morbidity (SMM)-and particularly cardiovascular SMM (cvSMM), the first cause of pregnancy-related mortality-has been rising in North America. Although hypertensive disorders of pregnancy (HDP) are common, their association with cvSMM specifically remains unclear.ObjectiveTo assess the association between individual subtypes of HDP and cvSMM, in addition to overall SMM, in a large, nationally representative sample.Design, setting, and participantsA population-based cohort study using the United States National Inpatient Sample was conducted. Individuals with obstetric deliveries between 2015 and 2019 were included. Data analysis was performed from October 2023 to February 2024.ExposureHDP subtypes included gestational hypertension, chronic hypertension, preeclampsia without severe features, severe preeclampsia, and HELLP (hemolysis, elevated liver enzymes, and low platelet) syndrome.Main outcomes and measuresThe primary outcome was a composite of cvSMM (including conditions such as pulmonary edema, stroke, and acute myocardial infarction) and the secondary outcome was a composite of overall SMM (including cvSMM and other conditions such as respiratory failure, severe postpartum hemorrhage, and sepsis). Adjusted risk ratios (aRRs) for the association between HDP subtypes and the outcomes were estimated using modified Poisson regression models adjusted for demographic and clinical characteristics.ResultsAmong 15 714 940 obstetric deliveries, 2 045 089 (13.02%) had HDP, 23 445 (0.15%) were affected by cvSMM, and 282 160 (1.80%) were affected by SMM. The mean (SD) age of the cohort was of 29 (6) years. The incidence of cvSMM was higher in participants with HDP than those without HDP (0.48% [9770 of 2 045 089] vs 0.10% [13 680 of 13 669 851]; P < .001). Participants with HELLP syndrome had the highest risk for cvSMM (aRR, 17.55 [95% CI, 14.67-21.01]), followed by severe preeclampsia (aRR, 9.11 [95% CI, 8.26-10.04]), and chronic hypertension (aRR, 3.57 [95% CI, 3.15-4.05]). Although HDP subtypes were also associated with overall SMM, the association with HELLP syndrome (aRR, 9.94 [95% CI, 9.44-10.45]), severe preeclampsia (aRR, 3.66 [95% CI, 3.55-3.78]), and chronic hypertension (aRR, 1.96 [95% CI, 1.88-2.03]) was attenuated compared with cvSMM.Conclusions and relevanceIn this cohort study, a graded relationship by severity characterized the association between HDP and cvSMM. Although all HDP subtypes were associated with an increased risk of overall SMM, the risk was more pronounced for cvSMM.
| S-EPMC11581633 | biostudies-literature
Project description:BackgroundMaternal mortality is still a major challenge for health systems, while severe maternal complications are the primary causes of maternal death. Our study aimed to determine whether severe maternal morbidity is effectively predicted by a newly proposed Modified Obstetric Early Warning Score (MOEWS) in the setting of an obstetric intensive care unit (ICU).MethodsA retrospective study of pregnant women admitted in the ICU from August 2019 to August 2020 was conducted. MOEWS was calculated 24 h before and 24 h after admission in the ICU, and the highest score was taken as the final value. For women directly admitted from the emergency department, the worst value before admission was collected. The aggregate performance of MOEWS in predicting critical illness in pregnant women was evaluated and finally compared with that of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score.ResultsA total of 352 pregnant women were enrolled; 290 women (82.4%) with severe maternal morbidity were identified and two of them died (0.6%). The MOEWSs of women with serious obstetric complications were significantly higher than those of women without serious obstetric complications [8(6, 10) vs. 4(2, 4.25), z = -10.347, P < 0.001]. MOEWSs of 24 h after ICU admission had higher sensitivity, specificity and AUROC than MOEWSs of 24 h before ICU admission. When combining the two MOEWSs, sensitivity of MOEWS was 99.3% (95% CI: 98-100), specificity 75.8% (95% CI: 63-86), positive predictive value (PPV) 95.1% (95% CI: 92-97) and negative predictive value (NPV) 95.9% (95% CI: 86-100). The areas under the receiver operator characteristic (ROC) curves of MOEWS were 0.92 (95% CI: 0.88-0.96) and 0.70 (95% CI: 0.63-0.76) of the APACHE II score.ConclusionThe newly proposed MOEWS has an excellent ability to identify critically ill women early and is more effective than APACHE II. It will be a valuable tool for discriminating severe maternal morbidity and ultimately improve maternal health.
| S-EPMC9720996 | biostudies-literature
Project description:BackgroundSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy increases the risk of adverse fetal and neonatal outcomes, but the contribution to severe maternal morbidity (SMM) has been less frequently documented.MethodsWe conducted a national cohort study of 93 624 deliveries occurring between 11 March 2020 and 1 July 2021 using medical claims information from the OptumLabs Data Warehouse. SARS-CoV-2 infection was identified from diagnostic and laboratory testing claims records. We identified 21 SMM conditions using International Classification of Diseases, Tenth Revision, Clinical Modification and procedure codes and compared SMM conditions by SARS-CoV-2 status using Poisson regression with robust variance, adjusting for maternal sociodemographic and health factors, onset of labor, and week of conception.ResultsApproximately 5% of deliveries had a record of SARS-CoV-2 infection: 27.0% <7 days before delivery, 13.5% within 7-30 days of delivery, and 59.5% earlier in pregnancy. Compared to uninfected pregnancies, the adjusted risk of SMM was 2.22 times higher (95% confidence interval [CI], 1.97-2.48) among those infected <7 days before delivery and 1.66 times higher (95% CI, 1.23-2.08) among those infected 7-30 days before delivery. The highest risks were observed for acute respiratory distress syndrome (adjusted risk ratio [aRR], 13.24 [95% CI, 12.86-13.61]) and acute renal failure (aRR, 3.91 [95% CI, 3.32-4.50]).ConclusionsCOVID-19 is associated with increased rates of SMM.
| S-EPMC10745255 | biostudies-literature
Project description:Using a cohort study design, we analysed 17 diagnoses and 9 interventions (including critical care admission) as a composite measure of severe maternal morbidity for pregnancies recorded over 14 years in Scotland. There were 762,918 pregnancies, of which 7947 (10 in 1000 pregnancies) recorded 9345 severe maternal morbidity events, 2802 episodes of puerperal sepsis being the most common (30%). Severe maternal morbidity incidence increased from 9 in 1000 pregnancies in 2012 to 17 in 1000 pregnancies in 2018, due in part to puerperal sepsis recording. The odds ratio (95%CI) for severe maternal morbidity was higher for: older women, for instance 1.22 (1.13-1.33) for women aged 35-39 years and 1.44 (1.27-1.63) for women aged > 40 years compared with those aged 25-29 years; obese women, for instance 1.13 (1.06-1.21) for BMI 30-40 kg.m-2 and 1.32 (1.15-1.51) for BMI > 40 kg.m-2 compared with BMI 18.5-24.9 kg.m-2 ; multiple pregnancy, 2.39 (2.09-2.74); and previous caesarean delivery, 1.52 (1.40-1.65). The median (IQR [range]) hospital stay was 3 (2-5 [1-8]) days with severe maternal morbidity and 2 (1-3 [1-5]) days without. Forty-one women died during pregnancy or up to 42 days after delivery, representing mortality rates per 100,000 pregnancies of about 365 with severe maternal morbidity and 1.6 without. There were 1449 women admitted to critical care, 807 (58%) for mechanical ventilation or support of at least two organs. We recorded an incidence of severe maternal morbidity higher than previously published, possibly because sepsis was coded inaccurately in our databases. Further research may determine the value of this composite measure of severe maternal morbidity.
| S-EPMC9544155 | biostudies-literature
Project description:In 2022, two novel classification systems for myelodysplastic syndromes/neoplasms (MDS) have been proposed: the International Consensus Classification (ICC) and the 2022 World Health Organization (WHO-2022) classification. These two contemporary systems exhibit numerous shared features but also diverge significantly in terminology and the definition of new entities. Thus, we retrospectively validated the ICC and WHO-2022 classification and found that both systems promoted efficient segregation of this heterogeneous disease. After examining the distinction between the two systems, we showed that a peripheral blood blast percentage ≥ 5% indicates adverse survival. Identifying MDS/acute myeloid leukemia with MDS-related gene mutations or cytogenetic abnormalities helps differentiate survival outcomes. In MDS, not otherwise specified patients, those diagnosed with hypoplastic MDS and single lineage dysplasia displayed a trend of superior survival compared to other low-risk MDS patients. Furthermore, the impact of bone marrow fibrosis on survival was less pronounced within the ICC framework. Allogeneic transplantation appears to improve outcomes for patients diagnosed with MDS with excess blasts in the ICC. Therefore, we proposed an integrated system that may lead to the accurate diagnosis and advancement of future research for MDS. Prospective studies are warranted to validate this refined classification.
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Project description:BackgroundHigh and low prepregnancy BMI are risk factors for severe maternal morbidity (SMM), but the contribution of gestational weight gain (GWG) is not well understood.ObjectivesWe evaluated associations between GWG and SMM by prepregnancy BMI group.MethodsWe analyzed administrative records from 2,483,684 Californian births (2007-2012), utilizing z score charts to standardize GWG for gestational duration. We fit the z scores nonlinearly and categorized GWG as above, within, or below the Institute of Medicine (IOM) recommendations after predicting equivalent GWG at term from the z score charts. SMM was defined using a validated index. Associations were estimated using multivariable logistic regression models.ResultsWe found generally shallow U-shaped relations between GWG z score and SMM in all BMI groups, except class 3 obesity (≥40 kg/m2), for which risk was lowest with weight loss. The weight gain amount associated with the lowest risk of SMM was within the IOM recommendations for underweight and class 2 obesity, but above the IOM recommendations for normal weight, overweight, and class 1 obesity. The adjusted risk ratios (RRs) and 95% CIs for GWG below the IOM recommendations, compared with GWG within the recommendations, were the following for underweight, normal weight, overweight, class 1 obesity, class 2 obesity, and class 3 obesity: 1.13 (0.99, 1.29), 1.09 (1.04, 1.14), 1.10 (1.01, 1.19), 1.07 (0.95, 1.21), 1.03 (0.88, 1.22), and 0.89 (0.73, 1.08), respectively. For GWG above the recommendations, the corresponding RRs and 95% CIs were 0.99 (0.84, 1.15), 1.04 (0.99, 1.08), 0.98 (0.92, 1.04), 1.03 (0.95, 1.13), 1.07 (0.94, 1.23), and 1.08 (0.91, 1.30), respectively.ConclusionsHigh and low GWG may be modestly associated with increased risk of SMM across BMI groups, except in women with class 3 obesity, for whom low weight gain and weight loss may be associated with decreased risk of SMM.
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