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Trauma in pregnancy: an underappreciated cause of maternal death
Editorials
ajog.org
Trauma in pregnancy: an underappreciated cause of maternal death Sarah J. Kilpatrick, MD, PhD
F
rom 1917 through 1980 the maternal mortality ratio (MMR) decreased dramatically from about 800 deaths per 100,000 live births to about 7.5/100,000.1-4 However, since 1980, maternal death in the United States has been not only impossible to reduce, but shown a steady increase reaching a MMR of 28/100,000 in 2014 and a pregnancy-related MMR of 17/100,000.2,5 There are multiple purported reasons including the increasing obesity rate, the higher percentage of older mothers, more women coming to pregnancy with underlying medical problems, differing methods of measuring rates, and the higher cesarean delivery rate. However, one aspect that cannot be overlooked is certainly the complacency, or the not so benign neglect, that occurred in those years when the mortality rate was at its nadir but not decreasing (1980 through 1999). Perhaps because the actual number of maternal deaths per year was low and, or, the concept that pregnant women are young and healthy, prevented us from recognizing that increasingly more women were dying. The good news is that there has been significant attention in the last 5-10 years with national efforts to reduce preventable pregnancy-related deaths and at least 1 state, California, has shown a decrease in such deaths.6-8 And yet, as the article in this issue by Deshpande et al9 so elegantly highlights, we are still not even counting a large proportion of maternal deaths because deaths from trauma are not captured under MMR or pregnancy-related maternal deaths. Deshpande et al9 report, in what is likely the largest study of pregnant trauma victims (1122 pregnant women over 10 years in 1 state), that not only is violent trauma significantly more common in pregnant (16%) compared to nonpregnant (10%) women, but that pregnant women were significantly more likely to die from trauma compared to nonpregnant women (P < .001). Further, violent trauma is more lethal for pregnant women than nonviolent trauma with 10% of pregnant women dying from violent trauma compared to 2.5% of pregnant women dying from nonviolent trauma (P < .02). Violent trauma in this study was defined as intentional trauma as
From the Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA. Received Sept. 13, 2017; accepted Sept. 13, 2017. The author reports no conflict of interest. Corresponding author: Sarah J. Kilpatrick, MD, PhD. Kilpatricks@cshs. org 0002-9378/free ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2017.09.012
Related article, page 590.
opposed to nonviolent or unintentional trauma. Finally, as they noted, trauma is not rare during pregnancy with approximately 9-10% of pregnant women exposed to trauma.9 So, trauma is common and deadly in pregnancy. What is also notable, and makes this article particularly important, is that the most commonly used statistics to characterize maternal death in the United States, the MMR (obstetric-related deaths within 6 weeks of pregnancy) or the pregnancy-related mortality ratio (pregnancy-related deaths within 1 year of pregnancy), do not include trauma-related deaths.3 Although a statistic called pregnancy-associated mortality (deaths due to any cause in pregnancy up to 1 year after pregnancy) that includes pregnancy-related deaths was intended to capture these trauma deaths by incorporating medical examiner data, hospital records, and birth and death certificate linkages, many if not most trauma-related deaths remain uncaptured.3,10 In Washington, DC, 43% of women who died from homicide and were pregnant were not captured in the pregnancy-related deaths reported.3 The concept that trauma-related maternal deaths are the leading cause of all maternal deaths is not new. Multiple reports in the 1990s reported exactly this.11-14 So once again we have been slow to address ongoing maternal deaths in the United States. Here we are again, 20 years later, complacently not paying attention as Deshpande et al9 suggest trauma could be associated with 20% of maternal death.9 Still not convinced we should care? In fact there are additional new articles reporting that trauma is the leading or significant cause of maternal death.15-17 Pregnant or postpartum women in Illinois were twice as likely to die from trauma than nonpregnant women and trauma-related maternal deaths were more common than deaths due to hemorrhage, emboli, hypertension, or sepsis.15 In Colorado, deaths due to self-harm were the leading cause of all maternal deaths and accounted for 30% of all deaths.17 These reports also provided data showing once again the disparities in risk factors for violent trauma in pregnancy with African American women and women with public, or no, insurance both significantly associated with violent trauma.9-11,15,17 Finally, it is likely that trauma-related deaths have a high degree of preventability since motor vehicle accidents and falls accounted for the majority (75%) of trauma cases in pregnant women with violent injury accounting for 16% of cases.9 What should be done in our efforts to reduce maternal deaths by whatever cause? In addition to focusing on current strategies of review and implementing guidelines and bundles we should capture trauma-related deaths. To review each of theseelooking for areas of improvementewould not take much effort. In this study the number of pregnant trauma cases was stable at only 115 per year and of those 1.8% died, NOVEMBER 2017 American Journal of Obstetrics & Gynecology
499
Editorials meaning that approximately 2 women died per year in their cohort.9 Shouldn’t the course of these women’s trauma and subsequent death be reviewed to look for preventable aspects? The authors mentioned key areas upon which to focus that improve outcomes, including better multidisciplinary training of emergency department and obstetric personnel to evaluate and manage pregnant trauma victims, and better screening of pregnant and postpartum women for intimate violence and psychiatric disease.9 Additional areas to be studied are seatbelt use by pregnant women, and reasons why pregnant women were more than twice as likely to be transferred to another hospital and less likely to be taken to the operating room than nonpregnant trauma victims.9 So, the bad news is that our maternal death rate is likely even higher than is now reported at 17-28/100,000 live births. But the good news might be that these deaths may be largely preventable if we can actually capture and study them, and implement change. This article is a call to action for those of us who care for pregnant women to advocate for the inclusion of trauma-related maternal deaths in our appropriate statistics and for their detailed review. It is time. And, finally, maybe it is also time to simplify our reporting of maternal deaths. Why are we only focused on pregnancy-related maternal deaths? Why don’t we make it easier: report and evaluate all pregnancy-associated deaths. Don’t we want to reduce all preventable deaths no matter the etiology? REFERENCES 1. Hoyert DL. Maternal mortality and related concepts. National Center for Health Statistics. Vital Health Stat 2007;3:1-13. 2. Joseph KS, Lisonkova S, Muraca GM, et al. Factors underlying the temporal increase in maternal mortality in the United States. Obstet Gynecol 2017;129:91-100. 3. Krulewitch CJ, Pierre-Louis ML, de Leon-Gomez R, et al. Hidden from view: violent deaths among pregnant women in the District of Columbia, 1988-1996. J Midwifery Womens Health 2001;46: 4-10.
500 American Journal of Obstetrics & Gynecology NOVEMBER 2017
ajog.org 4. MacDorman MF, Declercq E, Cabral H, et al. Recent increases in the US maternal mortality rate: disentangling trends from measurement issues. Obstet Gynecol 2016;128:447-55. 5. Centers for Disease Control and Prevention. Pregnancy mortality surveillance system. Available at: https://www.cdc.gov/reproductivehealth/ maternalinfanthealth/pmss.html. Accessed Sept. 11, 2017. 6. California Department of Public Health. Maternal mortality and the California pregnancy-associated mortality review (CA-PAMR). Available at: https://archive.cdph.ca.gov/data/statistics/Pages/CaliforniaPregnancyAssociatedMortalityReview.aspx. Accessed Sept. 11, 2017. 7. D’Alton ME, Main EK, Menard MK, et al. The National Partnership for Maternal Safety. Obstet Gynecol 2014;123:973-7. 8. Main EK, McCain CL, Morton CH, et al. Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities. Obstet Gynecol 2015;125:938-47. 9. Deshpande NA, Kucirka LM, Smith RN, Oxford CM. Pregnant trauma victims experience nearly 2-fold higher mortality compared to their nonpregnant counterparts. Am J Obstet Gynecol 2017;217:590.e1-9. 10. Wallace ME, Hoyert D, Williams C, et al. Pregnancy-associated homicide and suicide in 37 US states with enhanced pregnancy surveillance. Am J Obstet Gynecol 2016;215:364.e1-10. 11. Dannenberg AL, Carter DM, Lawson HW, et al. Homicide and other injuries as causes of maternal death in New York City, 1987 through 1991. Am J Obstet Gynecol 1995;172:1557-64. 12. Fildes J, Reed L, Jones N, et al. Trauma: the leading cause of maternal death. J Trauma 1992;32:643-5. 13. Mendez-Figueroa H, Dahlke JD, Vrees RA, et al. Trauma in pregnancy: an updated systematic review. Am J Obstet Gynecol 2013;209: 1-10. 14. Harper M, Parsons L. Maternal deaths due to homicide and other injuries in North Carolina: 1992-1994. Obstet Gynecol 1997;90: 920-3. 15. Koch AR, Rosenberg D, Geller SE, et al. Higher risk of homicide among pregnant and postpartum females aged 10-29 years in Illinois, 2002-2011. Obstet Gynecol 2016;128:440-6. 16. Mehta PK, Bachhuber MA, Hoffman R, et al. Deaths from unintentional injury, homicide, and suicide during or within 1 year of pregnancy in Philadelphia. Am J Public Health 2016;106: 2208-10. 17. Metz TD, Rovner P, Hoffman MC, et al. Maternal deaths from suicide and overdose in Colorado, 2004-2012. Obstet Gynecol 2016;128: 1233-40.
ajog.org
Trauma in pregnancy: an underappreciated cause of maternal death Sarah J. Kilpatrick, MD, PhD
F
rom 1917 through 1980 the maternal mortality ratio (MMR) decreased dramatically from about 800 deaths per 100,000 live births to about 7.5/100,000.1-4 However, since 1980, maternal death in the United States has been not only impossible to reduce, but shown a steady increase reaching a MMR of 28/100,000 in 2014 and a pregnancy-related MMR of 17/100,000.2,5 There are multiple purported reasons including the increasing obesity rate, the higher percentage of older mothers, more women coming to pregnancy with underlying medical problems, differing methods of measuring rates, and the higher cesarean delivery rate. However, one aspect that cannot be overlooked is certainly the complacency, or the not so benign neglect, that occurred in those years when the mortality rate was at its nadir but not decreasing (1980 through 1999). Perhaps because the actual number of maternal deaths per year was low and, or, the concept that pregnant women are young and healthy, prevented us from recognizing that increasingly more women were dying. The good news is that there has been significant attention in the last 5-10 years with national efforts to reduce preventable pregnancy-related deaths and at least 1 state, California, has shown a decrease in such deaths.6-8 And yet, as the article in this issue by Deshpande et al9 so elegantly highlights, we are still not even counting a large proportion of maternal deaths because deaths from trauma are not captured under MMR or pregnancy-related maternal deaths. Deshpande et al9 report, in what is likely the largest study of pregnant trauma victims (1122 pregnant women over 10 years in 1 state), that not only is violent trauma significantly more common in pregnant (16%) compared to nonpregnant (10%) women, but that pregnant women were significantly more likely to die from trauma compared to nonpregnant women (P < .001). Further, violent trauma is more lethal for pregnant women than nonviolent trauma with 10% of pregnant women dying from violent trauma compared to 2.5% of pregnant women dying from nonviolent trauma (P < .02). Violent trauma in this study was defined as intentional trauma as
From the Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA. Received Sept. 13, 2017; accepted Sept. 13, 2017. The author reports no conflict of interest. Corresponding author: Sarah J. Kilpatrick, MD, PhD. Kilpatricks@cshs. org 0002-9378/free ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2017.09.012
Related article, page 590.
opposed to nonviolent or unintentional trauma. Finally, as they noted, trauma is not rare during pregnancy with approximately 9-10% of pregnant women exposed to trauma.9 So, trauma is common and deadly in pregnancy. What is also notable, and makes this article particularly important, is that the most commonly used statistics to characterize maternal death in the United States, the MMR (obstetric-related deaths within 6 weeks of pregnancy) or the pregnancy-related mortality ratio (pregnancy-related deaths within 1 year of pregnancy), do not include trauma-related deaths.3 Although a statistic called pregnancy-associated mortality (deaths due to any cause in pregnancy up to 1 year after pregnancy) that includes pregnancy-related deaths was intended to capture these trauma deaths by incorporating medical examiner data, hospital records, and birth and death certificate linkages, many if not most trauma-related deaths remain uncaptured.3,10 In Washington, DC, 43% of women who died from homicide and were pregnant were not captured in the pregnancy-related deaths reported.3 The concept that trauma-related maternal deaths are the leading cause of all maternal deaths is not new. Multiple reports in the 1990s reported exactly this.11-14 So once again we have been slow to address ongoing maternal deaths in the United States. Here we are again, 20 years later, complacently not paying attention as Deshpande et al9 suggest trauma could be associated with 20% of maternal death.9 Still not convinced we should care? In fact there are additional new articles reporting that trauma is the leading or significant cause of maternal death.15-17 Pregnant or postpartum women in Illinois were twice as likely to die from trauma than nonpregnant women and trauma-related maternal deaths were more common than deaths due to hemorrhage, emboli, hypertension, or sepsis.15 In Colorado, deaths due to self-harm were the leading cause of all maternal deaths and accounted for 30% of all deaths.17 These reports also provided data showing once again the disparities in risk factors for violent trauma in pregnancy with African American women and women with public, or no, insurance both significantly associated with violent trauma.9-11,15,17 Finally, it is likely that trauma-related deaths have a high degree of preventability since motor vehicle accidents and falls accounted for the majority (75%) of trauma cases in pregnant women with violent injury accounting for 16% of cases.9 What should be done in our efforts to reduce maternal deaths by whatever cause? In addition to focusing on current strategies of review and implementing guidelines and bundles we should capture trauma-related deaths. To review each of theseelooking for areas of improvementewould not take much effort. In this study the number of pregnant trauma cases was stable at only 115 per year and of those 1.8% died, NOVEMBER 2017 American Journal of Obstetrics & Gynecology
499
Editorials meaning that approximately 2 women died per year in their cohort.9 Shouldn’t the course of these women’s trauma and subsequent death be reviewed to look for preventable aspects? The authors mentioned key areas upon which to focus that improve outcomes, including better multidisciplinary training of emergency department and obstetric personnel to evaluate and manage pregnant trauma victims, and better screening of pregnant and postpartum women for intimate violence and psychiatric disease.9 Additional areas to be studied are seatbelt use by pregnant women, and reasons why pregnant women were more than twice as likely to be transferred to another hospital and less likely to be taken to the operating room than nonpregnant trauma victims.9 So, the bad news is that our maternal death rate is likely even higher than is now reported at 17-28/100,000 live births. But the good news might be that these deaths may be largely preventable if we can actually capture and study them, and implement change. This article is a call to action for those of us who care for pregnant women to advocate for the inclusion of trauma-related maternal deaths in our appropriate statistics and for their detailed review. It is time. And, finally, maybe it is also time to simplify our reporting of maternal deaths. Why are we only focused on pregnancy-related maternal deaths? Why don’t we make it easier: report and evaluate all pregnancy-associated deaths. Don’t we want to reduce all preventable deaths no matter the etiology? REFERENCES 1. Hoyert DL. Maternal mortality and related concepts. National Center for Health Statistics. Vital Health Stat 2007;3:1-13. 2. Joseph KS, Lisonkova S, Muraca GM, et al. Factors underlying the temporal increase in maternal mortality in the United States. Obstet Gynecol 2017;129:91-100. 3. Krulewitch CJ, Pierre-Louis ML, de Leon-Gomez R, et al. Hidden from view: violent deaths among pregnant women in the District of Columbia, 1988-1996. J Midwifery Womens Health 2001;46: 4-10.
500 American Journal of Obstetrics & Gynecology NOVEMBER 2017
ajog.org 4. MacDorman MF, Declercq E, Cabral H, et al. Recent increases in the US maternal mortality rate: disentangling trends from measurement issues. Obstet Gynecol 2016;128:447-55. 5. Centers for Disease Control and Prevention. Pregnancy mortality surveillance system. Available at: https://www.cdc.gov/reproductivehealth/ maternalinfanthealth/pmss.html. Accessed Sept. 11, 2017. 6. California Department of Public Health. Maternal mortality and the California pregnancy-associated mortality review (CA-PAMR). Available at: https://archive.cdph.ca.gov/data/statistics/Pages/CaliforniaPregnancyAssociatedMortalityReview.aspx. Accessed Sept. 11, 2017. 7. D’Alton ME, Main EK, Menard MK, et al. The National Partnership for Maternal Safety. Obstet Gynecol 2014;123:973-7. 8. Main EK, McCain CL, Morton CH, et al. Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities. Obstet Gynecol 2015;125:938-47. 9. Deshpande NA, Kucirka LM, Smith RN, Oxford CM. Pregnant trauma victims experience nearly 2-fold higher mortality compared to their nonpregnant counterparts. Am J Obstet Gynecol 2017;217:590.e1-9. 10. Wallace ME, Hoyert D, Williams C, et al. Pregnancy-associated homicide and suicide in 37 US states with enhanced pregnancy surveillance. Am J Obstet Gynecol 2016;215:364.e1-10. 11. Dannenberg AL, Carter DM, Lawson HW, et al. Homicide and other injuries as causes of maternal death in New York City, 1987 through 1991. Am J Obstet Gynecol 1995;172:1557-64. 12. Fildes J, Reed L, Jones N, et al. Trauma: the leading cause of maternal death. J Trauma 1992;32:643-5. 13. Mendez-Figueroa H, Dahlke JD, Vrees RA, et al. Trauma in pregnancy: an updated systematic review. Am J Obstet Gynecol 2013;209: 1-10. 14. Harper M, Parsons L. Maternal deaths due to homicide and other injuries in North Carolina: 1992-1994. Obstet Gynecol 1997;90: 920-3. 15. Koch AR, Rosenberg D, Geller SE, et al. Higher risk of homicide among pregnant and postpartum females aged 10-29 years in Illinois, 2002-2011. Obstet Gynecol 2016;128:440-6. 16. Mehta PK, Bachhuber MA, Hoffman R, et al. Deaths from unintentional injury, homicide, and suicide during or within 1 year of pregnancy in Philadelphia. Am J Public Health 2016;106: 2208-10. 17. Metz TD, Rovner P, Hoffman MC, et al. Maternal deaths from suicide and overdose in Colorado, 2004-2012. Obstet Gynecol 2016;128: 1233-40.