Increased Risk of Severe Maternal Morbidity Among Refugees in Canada Attributable to High HIV Burden

Abstract Objective This study aimed to examine whether prenatal biochemical screening analytes are associated with an increased risk of severe maternal morbidity (SMM) or maternal mortality. Study Design This population-based cohort study includes all women in Ontario, Canada, who underwent prenatal screening from 2001 to 2011. Increasing fifth percentiles of the multiple of the median (MoM) for alphafetoprotein (AFP), total human chorionic gonadotropin, unconjugated estriol (uE3), dimeric inhibin-A (DIA), and pregnancy-associated plasma protein A were evaluated. An abnormally high concentration (>95th percentile MoM) for each analyte, individually and combined, was also evaluated. The main outcome assessed was the adjusted relative risk (aRR) of SMM or maternal mortality from 20 weeks' gestation up to 26 weeks thereafter. Results Among 748,972 pregnancies, 11,177 resulted in SMM or maternal mortality (1.5%). Except for uE3, the aRR of SMM or maternal mortality increased in association with increasing fifth percentiles of the MoM for all analytes. AFP (aRR: 2.10; 95% confidence interval [CI]: 1.97–2.25) and DIA (aRR: 2.33; 95% CI: 1.98–2.74) > 95th versus ≤ 5th percentile of the MoM were especially associated with SMM or death. Conclusion Women with abnormally high concentrations of certain prenatal biochemical analytes may be at a higher risk of SMM or death in pregnancy or postpartum.

Download Full-text

Interpregnancy Interval and Subsequent Severe Maternal Morbidity: A Population-based Study from California over 16 years

American Journal of Epidemiology ◽

10.1093/aje/kwab020 ◽

2021 ◽

Author(s):

Can Liu ◽

Jonathan M Snowden ◽

Deirdre J Lyell ◽

Elizabeth Wall-Wieler ◽

Barbara Abrams ◽

...

Keyword(s):

Maternal Age ◽

Maternal Morbidity ◽

Perinatal Outcomes ◽

Population Based ◽

Subsequent Pregnancy ◽

Severe Maternal Morbidity ◽

Interpregnancy Interval ◽

Adjusted Risk ◽

Index Pregnancy ◽

Increased Risk

Abstract Interpregnancy interval (IPI) associates with adverse perinatal outcomes, but its contribution to severe maternal morbidity (SMM) remains unclear. We examined the association between IPI and SMM, using data linked across sequential pregnancies to women in California 1997-2012. Adjusting for confounders measured at the index pregnancy (i.e. the first in a pair of consecutive pregnancies), we estimated adjusted risk ratios (aRRs) of SMM related to the subsequent pregnancy. We further conducted within-mother comparisons and analyses stratified by parity and maternal age at the index pregnancy. Compared to 18-23 months, IPI<6 months had same risk for SMM in between-mother comparison (aRR=0.96, 95%CI 0.91, 1.02) but lower risk in within-mother comparison (aRR=0.76, 95% confidence interval (CI) 0.67, 0.86). IPI 24-59 months and IPI≥60 months associated with increased risk of SMM in both between-mother (aRR=1.18, 95%CI 1.13, 1.23 and aRR=1.76, 95% CI 1.68, 1.85 respectively) and within-mother comparisons (aRR=1.22, 95%CI 1.11, 1.34 and aRR=1.88, 95% CI 1.66, 2.13 respectively). The association between IPI and SMM did not substantially differ by maternal age and parity. Longer IPI was associated with increased risk of SMM, which may be partly attributed to interpregnancy health.

Download Full-text

Increased risk of severe maternal morbidity (near-miss) among immigrant women in Sweden: a population register-based study

BJOG An International Journal of Obstetrics & Gynaecology ◽

10.1111/1471-0528.12326 ◽

2013 ◽

Vol 120 (13) ◽

pp. 1605-1612 ◽

Cited By ~ 28

Author(s):

Å Wahlberg ◽

M Rööst ◽

B Haglund ◽

U Högberg ◽

B Essén

Keyword(s):

Maternal Morbidity ◽

Immigrant Women ◽

Near Miss ◽

Severe Maternal Morbidity ◽

Population Register ◽

Increased Risk

Download Full-text

Increased risk of severe maternal morbidity among infertile women: analysis of US claims data

American Journal of Obstetrics and Gynecology ◽

10.1016/j.ajog.2020.02.027 ◽

2020 ◽

Vol 223 (3) ◽

pp. 404.e1-404.e20

Author(s):

Gayathree Murugappan ◽

Shufeng Li ◽

Ruth B. Lathi ◽

Valerie L. Baker ◽

Barbara Luke ◽

...

Keyword(s):

Maternal Morbidity ◽

Claims Data ◽

Severe Maternal Morbidity ◽

Infertile Women ◽

Increased Risk

Download Full-text

Hospital Safety-Net Burden and Risk for Readmissions and Severe Maternal Morbidity

American Journal of Perinatology ◽

10.1055/s-0040-1710544 ◽

2020 ◽

Author(s):

Lilian P. McKinley ◽

Timothy Wen ◽

Cynthia Gyamfi-Bannerman ◽

Jason D. Wright ◽

Dena Goffman ◽

...

Keyword(s):

Maternal Morbidity ◽

Obstetric Care ◽

Safety Net ◽

Severe Maternal Morbidity ◽

Linear Regression Models ◽

Maternal Risk ◽

High Burden ◽

Hospital Safety ◽

Increased Risk ◽

Log Linear

Abstract Objective This study aimed to analyze whether hospital safety-net burden status is associated with increased risk for severe maternal morbidity (SMM) and postpartum readmissions. Study Design The 2010 to 2014 Nationwide Readmissions Database was utilized for this retrospective cohort study. Hospitals were categorized as high-burden hospitals (25% of hospitals with the highest safety-net burden), medium-burden hospitals (50% of hospitals with intermediate safety-net burden), and low-burden hospitals (25% of hospitals with the lowest safety-net burden) based on the proportions of Medicaid or uninsured patients. Risk for (1) SMM, (2) 60-day postpartum readmissions, and (3) SMM during postpartum readmissions was analyzed. Unadjusted and adjusted log-linear regression models were performed, respectively, for these outcomes with unadjusted risk ratio (RR) and adjusted RR (aRR) as measures of effect. Adjusted models included demographic, hospital, and clinical factors. Results High-burden safety-net status was associated with increased risk for SMM compared with low-burden safety-net status in both unadjusted (RR: 1.51, 95% confidence interval [CI]: 1.50–1.53) and adjusted analyses (aRR: 1.27, 95% CI: 1.25–1.30). High-burden status was also associated with increased risk for readmissions in unadjusted analyses (RR: 1.42, 95% CI: 1.40–1.44), although this risk was attenuated in adjusted analyses (aRR: 1.07, 95% CI: 1.06–1.08). High-burden status was associated with significantly increased risk for readmission for uterine infections, hypertensive diseases of pregnancy, and psychiatric diagnoses. High-burden status was not associated with severe morbidity during readmissions in adjusted or unadjusted analyses (RR: 1.02, 95% CI: 0.98–1.05; aRR: 0.95, 95% CI: 0.92–0.99). Conclusion This study found that high safety-net burden hospitals may be a higher risk setting for obstetric care. Improvement of outcomes in high-burden settings may be important in overall efforts to reduce maternal risk.

Download Full-text

Association between legal status, prenatal care utilization, severe perinatal and maternal morbidity

European Journal of Public Health ◽

10.1093/eurpub/ckz185.273 ◽

2019 ◽

Vol 29 (Supplement_4) ◽

Author(s):

M Eslier ◽

T Schmitz ◽

D Luton ◽

L Mandelbrot ◽

C Estellat ◽

...

Keyword(s):

Prenatal Care ◽

Maternal Morbidity ◽

Legal Status ◽

Severe Maternal Morbidity ◽

Care Utilization ◽

Hypertensive Disorder ◽

Prenatal Care Utilization ◽

Increased Risk ◽

Hypertensive Disorder Of Pregnancy ◽

Inadequate Prenatal Care

Abstract Background Some groups of migrant women have a higher risk of inadequate prenatal care utilization (PCU), severe maternal morbidity (SMM) and severe perinatal morbidity (SPM). To better understand this association, our aim was to assess the association between the legal status and PCU, SMM and SPM during pregnancy. Methods The analysis was performed in the database of the multicenter prospective PreCARE cohort. All pregnant women registered for delivery in 4 university hospital maternity units in Paris north area from October 2010 to May 2012 were included (N = 10 419). Women whose pregnancies ended before 22 weeks of gestation or who delivered in another maternity unit were excluded (N = 820). Women were distributed according to legal status in 4 groups: non-migrants, migrants with French or European nationality, legal migrants and undocumented migrants. The associations between the legal status and the composite variables of prenatal care utilization, SMM and SPM were tested through multivariate logistic regressions also adjusted for maternal characteristics. Results The illegal status was associated with increased risk of inadequate prenatal care utilization [adjusted odds ratio (aOR) 2,52 (2,10 - 3,01)]. Overall, the prevalence of SMM was 3,2 % and SPM 7,0 %. The illegal status was associated with higher risk of SMM [aOR 1,84 (1,21 - 2,79)], especially severe hypertensive disorder of pregnancy [aOR 2,29 (1,19 - 4,40)]. However, no significant association with SPM was found [aOR 1,29 (0,95 - 1,74)]. The sensitivity analysis demonstrates that results do not change after exclusion of women who arrived less than 12 months before delivery and those who started their follow-up after 14 weeks of gestation. Conclusions The illegal status was associated with an inadequate prenatal care utilization and a higher risk of SMM, especially severe hypertensive disorder of pregnancy. Key messages The illegal status was associated with increased risk of inadequate prenatal care utilization. The illegal status was associated with higher risk of severe maternal morbidity during pregnancy.

Download Full-text

Weight gain during pregnancy and the risk of severe maternal morbidity by prepregnancy BMI

American Journal of Clinical Nutrition ◽

10.1093/ajcn/nqaa033 ◽

2020 ◽

Vol 111 (4) ◽

pp. 845-853

Author(s):

Stephanie A Leonard ◽

Barbara Abrams ◽

Elliott K Main ◽

Deirdre J Lyell ◽

Suzan L Carmichael

Keyword(s):

Weight Loss ◽

Weight Gain ◽

Maternal Morbidity ◽

Normal Weight ◽

Severe Maternal Morbidity ◽

Z Score ◽

Prepregnancy Bmi ◽

Increased Risk ◽

Class 1 ◽

Iom Recommendations

ABSTRACT Background High and low prepregnancy BMI are risk factors for severe maternal morbidity (SMM), but the contribution of gestational weight gain (GWG) is not well understood. Objectives We evaluated associations between GWG and SMM by prepregnancy BMI group. Methods We 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. Results We 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. Conclusions High 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.

Download Full-text

The Burden of Indirect Causes of Maternal Morbidity and Mortality in the Process of Obstetric Transition: A Cross-Sectional Multicenter Study

Revista Brasileira de Ginecologia e Obstetrícia / RBGO Gynecology and Obstetrics ◽

10.1055/s-0038-1623511 ◽

2018 ◽

Vol 40 (03) ◽

pp. 106-114 ◽

Cited By ~ 5

Author(s):

Jessica Cirelli ◽

Fernanda Surita ◽

Maria Costa ◽

Mary Parpinelli ◽

Samira Haddad ◽

...

Keyword(s):

Maternal Death ◽

Maternal Morbidity ◽

Kidney Diseases ◽

Secondary Analysis ◽

Perinatal Outcomes ◽

Prevalence Ratio ◽

H1n1 Influenza ◽

Severe Maternal Morbidity ◽

Cross Sectional ◽

Increased Risk

Objective The aim of this study is to evaluate the burden of indirect causes of maternal morbidity/mortality in Brazil. Methods Secondary analysis of a multicenter cross-sectional study conducted in 27 referral obstetric units within the Brazilian Network for Surveillance of Severe Maternal Morbidity. Results A total of 82,388 women were surveilled: 9,555 women with severe maternal morbidity were included, and 942 (9.9%) of them had indirect causes of morbidity/mortality. There was an increased risk of higher severity among the indirect causes group, which presented 7.56 times increased risk of maternal death (prevalence ratio [PR]: 7.56; 95% confidence interval [95%CI]: 4.99–11.45). The main indirect causes of maternal death were H1N1 influenza, sepsis, cancer and cardiovascular disease. Non-public antenatal care (PR: 2.52; 95%CI: 1.70–3.74), diabetes (PR: 1.90; 95%CI: 1.24–2.90), neoplasia (PR: 1.98; 95%CI: 1.25–3.14), kidney diseases (PR: 1.99; 95%CI: 1.14–3.49), sickle cell anemia (PR: 2.50; 95%CI: 1.16–5.41) and drug addiction (PR: 1.98; 95%CI: 1.03–3.80) were independently associated with worse results in the indirect causes group. Some procedures for the management of severity were more common for the indirect causes group. Conclusion Indirect causes were present in less than 10% of the overall cases, but they represented over 40% of maternal deaths in the current study. Indirect causes of maternal morbidity/mortality were also responsible for an increased risk of higher severity, and they were associated with worse maternal and perinatal outcomes. In middle-income countries there is a mix of indirect causes of maternal morbidity/mortality that points to some advances in the scale of obstetric transition, but also reveals the fragility of health systems.

Download Full-text

Severe Maternal Morbidity Associated with Systemic Lupus Erythematosus Flare in the Second Trimester of Pregnancy

Case Reports in Obstetrics and Gynecology ◽

10.1155/2018/5803479 ◽

2018 ◽

Vol 2018 ◽

pp. 1-6

Author(s):

Matthew J. Blitz ◽

Adiel Fleischer

Keyword(s):

Systemic Lupus Erythematosus ◽

Lupus Erythematosus ◽

Maternal Morbidity ◽

Cytotoxic Agents ◽

Severe Maternal Morbidity ◽

Laboratory Evaluation ◽

Management Approach ◽

Systemic Lupus ◽

Increased Risk ◽

Neuropsychiatric Sle

Pregnancy in women with systemic lupus erythematosus (SLE) is associated with an increased risk of adverse maternal and fetal outcomes. Here, we present a case of severe maternal morbidity in a 23-year-old primigravida with SLE and secondary Sjögren’s syndrome who experienced a life-threatening multisystem flare at 17 weeks of gestational age. She presented to the emergency department complaining of cough with hemoptysis and shortness of breath. She developed hypoxic respiratory failure and was admitted to the intensive care unit. Bronchoscopy confirmed diffuse alveolar hemorrhage. Physical exam and laboratory evaluation were consistent with an active SLE flare, pancytopenia, and new-onset lupus nephritis. After counseling regarding disease severity, poor prognosis, and recommendation for therapy with cytotoxic agents, she agreed to interruption of pregnancy which was achieved by medical induction. Her course was further complicated by thrombotic microangiopathy and generalized tonic-clonic seizures attributable to posterior reversible encephalopathy syndrome versus neuropsychiatric SLE. This case represents one of the most extreme manifestations of lupus disease activity associated with pregnancy that has been reported in the literature and emphasizes the importance of preconception evaluation and counseling and a multidisciplinary management approach in cases with a complex and evolving clinical course.

Download Full-text