Maternal Morbidity Resources

Objective: The purpose of this study was to evaluate the relationship between prepregnancy maternal body mass index and spontaneous preterm birth and indicated preterm birth. Study design: This was a secondary analysis of the Maternal-Fetal Medicine Units Network, Preterm Prediction study. Patients were classified into categories that were based on their body mass index. Rates of indicated and spontaneous preterm birth were compared. Results: Five hundred ninety-seven (20.5%) of 2910 women were obese. Obese women had fewer spontaneous preterm births at !37 weeks of gestation (6.2% vs 11.2%; P ! .001) and at !34 weeks of gestation (1.5% vs 3.5%; P =.012). Women with a body mass index of !19 kg/m2 had 16.6% spontaneous preterm birth, with a body mass index of 19 to 24.9 kg/m2 had 11.3% spontaneous preterm birth, with a body mass index of 25 to 29.9 kg/m2 had 8.1% spontaneous preterm birth, with a body mass index of 30 to 34.9 kg/m2 had 7.1% spontaneous preterm birth, and with a body mass index of R35 kg/m2 had 5.2% spontaneous preterm birth (P ! .0001). Indicated delivery was responsible for an increasing proportion of preterm births with increasing body mass index (P= .001). Obese women had lower rates of cervical length !25 mm (5% vs 8%; P =.012). Multivariable regression analysis confirmed a lower rate of spontaneous preterm birth in obese gravid women (odds ratio, 0.57; 95% CI, 0.39-0.83; P =.003). Conclusion: Obesity before pregnancy is associated with a lower rate of spontaneous preterm birth.

OBJECTIVE: Amniotic fluid embolism (AFE) is a condition occurring during delivery that can lead to severe maternal morbidity and mortality. Given the rarity of its occurrence, current estimates and predictors of the incidence and outcomes are often difficult to obtain.
STUDY DESIGN: We conducted a population-based cohort study on 3 million birth records in the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 1999 to 2003 to estimate the incidence and case fatality of AFEs. Logistic regression was used to calculate the odds ratio (OR) and corresponding 95% confidence intervals (CIs) of demographic and obstetrical determinants of AFEs and fatal AFEs.
RESULTS: The overall incidence of AFE was 7.7 per 100,000 births (95% CI 6.7 to 8.7), with a case fatality rate of 21.6% (95% CI 15.5 to 27.6%). AFE was associated with maternal age greater than 35 (OR 2.2, 95% CI 1.5 to 2.1), placenta previa (OR 30.4, 95% CI 15.4 to 60.1), and cesarean delivery (OR 5.7, 95% CI 3.7 to 8.7). Although AFEs were not significantly associated with induction of labor (OR 1.5, 95% CI 0.9 to 2.3), they were associated with preeclampsia, abruptio placentae, and the use of forceps. Among women with an AFE, common demographic or obstetrical determinants were not predictive of maternal mortality.
CONCLUSION: AFE is a rare but serious condition that is associated with advanced maternal age, placental pathologies, and cesarean deliveries. Further research on the treatment of this condition is necessary.

Pregnant women have a fourfold to fivefold increased risk of thromboembolism compared with nonpregnant women (1, 2). Approximately 80% of thromboembolic events in pregnancy are venous (3), with a prevalence of 0.5–2.0 per 1,000 pregnant women (4–9). Venous thromboembolism, including pulmonary embolism, accounts for 1.1 deaths per 100,000 deliveries (3), or 9 % of all maternal deaths in the United States (10). In the developing world, the leading cause of maternal death is hemorrhage (11); however, in developed nations, where hemorrhage is more often successfully treated and prevented, thromboembolic disease is one of the leading causes of death (12). The prevalence and severity of this condition during pregnancy and the peripartum period warrant special consideration of management and therapy. Such therapy includes the treatment of acute thrombotic events and prophylaxis for those at increased risk of thrombotic events. The purpose of this document is to provide information regarding the risk factors, diagnosis, management, and prevention of thromboembolism, particularly venous thromboembolism in pregnancy.

Hypertensive disease occurs in approximately 12–22% of pregnancies, and it is directly responsible for 17.6% of maternal deaths in the United States (1, 2). However, there is confusion about the terminology and classification of these disorders. This bulletin will provide guidelines for the diagnosis and management of hypertensive disorders unique to pregnancy (ie, preeclampsia and eclampsia), as well as the various associated complications. Chronic hypertension has been discussed elsewhere (3).

Acute-onset, persistent (lasting 15 minutes or more), severe systolic (greater than or equal to 160 mm HG) or severe diastolic hypertension (greater than or equal to 110 mm HG) or both in pregnant or postartum women with preeclampsia or eclampsia constitutes a hypertensive emergency. Severe systolic hypertension may be the most important predictor of cerebral hemorrhage and infarction in these patients and if not treated expeditiously can result in maternal death. Intravenous labetalol and hydralazine are both considered first-line drugs for the management of acute, severe hypertension in this clinical setting. Close maternal and fetal monitoring by the physician and nursing staff are advised. Order sets for the use of labetalol and hydralazine for the initial management of acute, severe hypertension in pregnant or postpartum women with preeclampsia or eclampsia have been developed.

ABSTRACT: Hypertensive disease occurs in approximately 12-22% of pregnancies, and it is directly responsible for 17.6% of maternal deaths in the United States ( 1,2). However, there is confusion about the terminology and classification of these disorders. This bulletin will provide guidelines for the diagnosis and management of hypertensive disorders unique to pregnancy (ie, preeclampsia and eclampsia), as well as the various associated complications. Chronic hypertension has been discussed elsewhere ( 3). (C) 2002 The American College of Obstetricians and Gynecologists

Preeclampsia is a major cause of maternal and fetal morbidity and mortality worldwide, however, its etiology remains unclear. Abnormal placental angiogenesis during pregnancy resulting from high levels of anti-angiogenic factors, soluble Flt1 (sFlt1) and soluble endoglin (sEng), has been implicated in preeclampsia pathogenesis. Accumulating evidence also points to a role for these anti-angiogenic proteins as serum biomarkers for the clinical diagnosis and prediction of preeclampsia. Uncovering the mechanisms of altered angiogenic factors in preeclampsia may also provide insights into novel preventive and therapeutic options.

OBJECTIVE: To describe the incidence of eclampsia in women with mild gestational hypertension when only women with severe gestational hypertension are given magnesium sulfate prophylaxis. METHODS: This is a prospective 41⁄2-year observational study. Those women who met our criteria for severe gestational hypertension received intravenous magnesium sulfate prophylaxis, and women with nonsevere hypertension did not. Data were collected at delivery to ascertain the incidence of eclampsia and maternal and neonatal morbidity. RESULTS: A total of 72,004 women were delivered during the study period, 6,431 had gestational hypertension, 3,935 met the criteria for severe disease and were given magnesium sulfate prophylaxis, 2,496 women with nonsevere hypertension were not treated. Eighty-seven women developed eclampsia, for an overall incidence of 1 in 828 deliveries, a 50% increase when compared with 5 preceding years where all women with gestational hypertension were given magnesium sulfate prophylaxis. Of the 2,496 women with nonsevere hypertension who were not treated, 27 had eclampsia (1 in 92). Women with eclampsia were more likely to require general anesthesia for cesarean delivery compared with hypertensive women without eclampsia (23% versus 4%, P<.001), but they had no additional morbidity. Infants of eclamptic mothers had more adverse outcomes than those without convulsions (12% versus 1%, P<.04). CONCLUSION: Selective magnesium sulfate prophylaxis results in an increased overall incidence of eclampsia because of more seizures in women with nonsevere gestational hypertension who are not given magnesium sulfate prophylaxis.

Objective: To assess whether advanced maternal age modifies the relationship between maternal pregravid weight status, gestational weight gain patterns, and the occurrence of spontaneous preterm birth (SPB) and medically indicated preterm birth (MIPB). Methods: Retrospective cohort analysis of vital statistics data from the state of Florida for the period 2004 through 2007 comprising 311,422 singleton pregnancies (two age groups: 20–24 years old or younger women and ≥35 years or older women). Mothers were classified into five clusters based on their prepregnancy body mass index (BMI) values: non-obese (less than 30), class I obese (30.0≤BMI≤34.9), class II obese (35.0≤BMI≤39.9), class III obese (40≤BMI≤49.9), and super-obese (BMI≥50.0). Results: MIPB occurred more frequently among older than younger women [11.8% vs. 6.4%, respectively (p < 0.0001)) whereas SPB occurred more frequently among youngerwomen[11.3% vs. 10.5%, respectively (p < 0.0001)). Maternal obesity increased the risk forMIPBbut not for SPB. Regardless ofBMIstatus, the risk of MIPB was elevated among older mothers, particularly among those with suboptimal (<0.23 kg/week) and supraoptimal (>0.68 kg/week) gestational weight gain. A dose–response relationship with increasing gestational weight gain was evident (p < 0.01); the greatest risk for MIPB occurred among older mothers with weekly gestational weight gain in excess of 0.79 kg (OR = 7.76, 95% CI = 5.73–10.5). Conclusion: The occurrence of medically indicated preterm birth is positively associated with increased maternal pregravid body weight, older maternal age and extremes of gestational weight gain. Targeted pre- and inter-conception weight management efforts should be particularly encouraged in older mothers.

OBJECTIVE: To estimate the maternal morbidity associated with cesarean deliveries performed at term without labor compared with morbidity associated with induction of labor at term.
METHODS: A 15-year population-based cohort study (1988-2002) using the Nova Scotia Atlee Perinatal Database compared maternal outcomes in nulliparous women delivering by cesarean delivery without labor and nulliparous women at term undergoing induction of labor for planned vaginal delivery with singleton, cephalic presentation.
RESULTS: A total of 5,779 pregnancies satisfied inclusion and exclusion criteria, 879 of which were cesarean deliveries without labor. There were no maternal deaths. There was no difference in wound infection, puerperal febrile morbidity, blood transfusion or intraoperative trauma. After controlling for potential confounders, women undergoing cesarean delivery without labor were less likely to have complications of early postpartum hemorrhage (relative risk 0.61, 95% confidence interval 0.42-0.88, number needed to treat 32) and composite maternal morbidity (relative risk 0.71, 95% confidence interval 0.52-0.95, number needed to treat 34) compared with women undergoing induction of labor. Subgroup analyses of maternal outcomes after induction of labor in women by method of delivery were also performed and demonstrated additional risks of traumatic morbidity after induction of labor. The highest morbidity was found in the assisted vaginal delivery and cesarean delivery in labor groups.
CONCLUSION: Early postpartum hemorrhage and composite maternal morbidity were decreased in cesarean delivery without labor compared with induction of labor. Hemorrhagic and traumatic morbidities with labor induction are increased after assisted vaginal delivery and cesarean delivery in labor compared with cesarean delivery without labor.

OBJECTIVE: To estimate and evaluate the demographics, clinical course, and complications of delayed postpartum preeclampsia in patients with and without eclampsia. METHODS: We conducted a retrospective cohort study of patients who were discharged and later readmitted with the diagnosis of delayed postpartum preeclampsia more than 2 days to 6 weeks or less after delivery between January 2003 and August 2009. RESULTS: One hundred fifty-two patients met criteria for the diagnosis of delayed postpartum preeclampsia. Of these, 96 (63.2%) patients had no antecedent diagnosis of hypertensive disease in the current pregnancy, whereas seven (4.6%), 14 (9.2%), 28 (18.4%), and seven (4.6%) patients had gestational hypertension, chronic hypertension, preeclampsia, and preeclampsia superimposed on chronic hypertension, respectively, during the peripartum period. Twenty-two patients (14.5%) developed postpartum eclampsia, and more than 90% of these patients presented within 7 days after discharge from the hospital. The most common presenting symptom was headache in 105 (69.1%) patients. Patients who developed eclampsia were significantly younger than those who did not (mean
standard deviation, 23.2
6.2 compared with 28.3
6.7 years; adjusted odds ratio [OR] 1.13, 95% confidence interval [CI] 1.02–1.26, P.03), and other demographic variables were no different. A lower readmission hemoglobin was associated with a lower odds of progression to eclampsia (10.7
1.7 compared with 11.6
2.2 g/dL, adjusted OR 0.75, 95% CI 0.57–0.98, P.04). CONCLUSION: One week after discharge appears to be a critical period for the development of postpartum eclampsia. Education about the possibility of delayed postpartum preeclampsia and eclampsia should occur after delivery, whether or not patients develop hypertensive disease before discharge from the hospital.

Objective: We aimed at (a) examining the rates of obesity over a 12-year period; (b) studying the effect of obesity and morbid obesity on gestational age and birth weight and (c) determining the influence of race on the association between maternal obesity and the gestational age of a newborn. Study Design: We conducted a retrospective analysis using data from the perinatal data set of mothers delivering at the George Washington University between 1992 and 2003. We stratified mother/infant pairs (n¼14 183) into three groups on the basis of maternal prepregnancy body mass index (BMI): not obese (BMI<30), obese (BMI 30 to 39) and morbidly obese (BMIX40). We identified all spontaneous and induced preterm deliveries in each group. Bivariate and multivariate analyses were conducted to control for significant differences between groups. Result: We identified obesity in 1707 (12%) and morbid obesity in 415 (3%) of the mothers. Obesity and morbid obesity increased over time during the study period. In crude analysis, mothers with obesity and morbid obesity were more likely to deliver prematurely (16.7 and 20.3%, respectively) when compared with nonobese women (14.5%), and were also more likely to have other complications including smoking, anemia, hypertension, diabetes and cesarean delivery. When controlling for these complications in a logistic regression model, obesity and morbid obesity were not associated with prematurity. Conclusion: There is no direct link between obesity and prematurity. Prematurity is more likely caused by medical complications that frequently occur in obese women. Further studies are needed on this growing population to test whether providing adequate prenatal care can control the associated medical conditions and subsequently ameliorate the rate of prematurity. Journal of Perinatology (2010) 30, 447–451; doi:10.1038/jp.2009.117; published online 20 August 2009 Keywords: body mass index; BMI; low birth weight; African-American; logistic regression analysis; preeclampsia.

Ideally ACLS providers will prevent pulseless arrest if they are able to intervene in the prearrest period. If arrest occurs, good ACLS begins with high-quality BLS. During resuscitation rescuers must provide good chest compressions (adequate rate and depth), allow complete recoil of the chest between compressions, and minimize interruptions in chest compressions. Rescuers should be careful to avoid provision of excessive ventilation, particularly once an advanced airway is in place. Resuscitation drugs have not been shown to increase rate of survival to hospital discharge, and none has the impact of early and effective CPR and prompt defibrillation.

Successful resuscitation of a pregnant woman and survival of the fetus require prompt and excellent CPR with some modifications in basic and advanced cardiovascular life support techniques. By the 20th week of gestation, the gravid uterus can compress the inferior vena cava and the aorta, obstructing venous return and arterial blood flow. Rescuers can relieve this compression by positioning the woman on her side or by pulling the gravid uterus to the side. Defibrillation and medication doses used for resuscitation of the pregnant woman are the same as those used for other adults in pulseless arrest. Rescuers should consider the need for emergency hysterotomy as soon as the pregnant woman develops cardiac arrest because rescuers should be prepared to proceed with the hysterotomy if the resuscitation is not successful within minutes.

Spontaneous subarachnoid hemorrhage due to ruptured berry aneurysm and arteriovenous malformation accounted for 4.4 per cent of all maternal deaths in the State of Minnesota from 1950 to 1973. This catastrophic entiity ranked eighth in frequency regarding all causes of death and third among the nonobstetric causes. An analysis of the 37 deaths among 1,763,824 live births is presented. These 37 patients had delivered 96 infants and had 10 spontaneous abortions prior to current pregnancy. This suggest that pregnancy per se has no appreciable effect upon the occurrence of the hemorrhage. Five of these died in association with labor and delivery, or during a 1 day period-three during labor, one during vaginal delivery, and one only 1 hour postpartum. This is equivalent to 35 per week. On the other hand, 15 occurred during pregnancy (underlivered) (0.4 per week) and 17 during the first 3 months post partum (1.4 per week). These data seem to indicate that labor and delivery increase the risk of spontaneous subarachnoid hemorrhage. The neurologic state of these 37 patients was bad from the very onset of the hemorrhage. Rapid irreversible coma occurred in 34 (76 per cent). Of these 34, 24 (74 per cent) were dead within the first 24 hours and 32 (94 per cent) were dead within the first 4 days following the onset of the hemorrhage.

Using a provincial perinatal database for 15 years, 1988-2002. Cases were identified with one or more of the following markers of severe maternal morbidity: blood transfusion > or = 5 units, emergency hysterectomy, uterine rupture, eclampsia, intensive care (ICU) admission. There were 159,896 mothers delivered of whom 313 (2.0/1000) had 385 markers of severe morbidity (257 had one, 42 had two, 12 had three, and two had four). The following rates of morbidity were recorded: blood transfusion > or = 5 units 119 (0.74/1000); emergency hysterectomy 88 (0.55/1000); uterine rupture 49 (0.31/1000); eclampsia 46 (0.28/1000); ICU 83 (0.52/1000). There was a statistically significant association between multiparity > or = 1, and emergency hysterectomy and uterine rupture; between age > or = 35 years, and emergency hysterectomy, uterine rupture and ICU; and between caesarean delivery and blood transfusion > or = 5 units, emergency hysterectomy, uterine rupture, eclampsia and ICU. The main contributing obstetric complications were haemorrhage (64.7%) and complications of hypertensive disorders (16.8%).

OBJECTIVE: To determine the level of near-miss maternal mortality and morbidity due to severe obstetrical complications or maternal disease in a tertiary maternity hospital.
DESIGN: Retrospective review.
SETTING: A free-standing maternity hospital delivering 5500 infants per year.
METHODS: The information coded in the perinatal database concerning women who had required transfer for critical care to a general hospital was reviewed for the 14 year period 1980 to 1993. The complications necessitating transfer and the specialised consultants and services required were noted.
RESULTS: Over 14 years there were 76,119 women delivered with two maternal deaths (2.6/100,000). Fifty-five women required transfer for critical care (0.7/1000). The main reasons for transfer were hypertensive disease (25%), haemorrhage (22%) and sepsis (15%). Transfer to an intensive care unit was required by 80%, and the remainder were transferred to specialised medical or surgical units. Twenty different specialist groups were consulted. The 55 patients spent 280 days in critical care and 464 days hospital after-care (mean 13 days, range 3-92).
CONCLUSION: A review of near-miss maternal mortality helps delineate the continuing threats to maternal health and the type of support services most commonly required.

This article discusses the management of venous thromboembolism (VTE) and thrombophilia, as well as the use of antithrombotic agents, during pregnancy and is part of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that benefits do, or do not, outweigh risks, burden, and costs. Grade 2 recommendations are weaker and imply that the magnitude of the benefits and risks, burden, and costs are less certain. Support for recommendations may come from high-quality, moderate-quality or low-quality studies; labeled, respectively, A, B, and C. Among the key recommendations in this chapter are the following: for pregnant women, in general, we recommend that vitamin K antagonists should be substituted with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) [Grade 1A], except perhaps in women with mechanical heart valves. For pregnant patients, we suggest LMWH over UFH for the prevention and treatment of VTE (Grade 2C). For pregnant women with acute VTE, we recommend that subcutaneous LMWH or UFH should be continued throughout pregnancy (Grade 1B) and suggest that anticoagulants should be continued for at least 6 weeks postpartum (for a total minimum duration of therapy of 6 months) [Grade 2C]. For pregnant patients with a single prior episode of VTE associated with a transient risk factor that is no longer present and no thrombophilia, we recommend clinical surveillance antepartum and anticoagulant prophylaxis postpartum (Grade 1C). For other pregnant women with a history of a single prior episode of VTE who are not receiving long-term anticoagulant therapy, we recommend one of the following, rather than routine care or full-dose anticoagulation: antepartum prophylactic LMWH/UFH or intermediate-dose LMWH/UFH or clinical surveillance throughout pregnancy plus postpartum anticoagulants (Grade 1C). For such patients with a higher risk thrombophilia, in addition to postpartum prophylaxis, we suggest antepartum prophylactic or intermediatedose LMWH or prophylactic or intermediate-dose UFH, rather than clinical surveillance (Grade 2C). We suggest that pregnant women with multiple episodes of VTE who are not receiving long-term anticoagulants receive antepartum prophylactic, intermediate-dose, or adjusted-dose LMWH or intermediate or adjusted-dose UFH, followed by postpartum anticoagulants (Grade 2C). For those pregnant women with prior VTE who are receiving long-term anticoagulants, we recommend LMWH or UFH throughout pregnancy (either adjusted-dose LMWH or UFH, 75% of adjusted-dose LMWH, or intermediate-dose LMWH) followed by resumption of long-term anticoagulants postpartum (Grade 1C). We suggest both antepartum and postpartum prophylaxis for pregnant women with no prior history of VTE but antithrombin deficiency (Grade 2C). For all other pregnant women with thrombophilia but no prior VTE, we suggest antepartum clinical surveillance or prophylactic LMWH or UFH, plus postpartum anticoagulants, rather than routine care (Grade 2C). For women with recurrent early pregnancy loss or unexplained late pregnancy loss, we recommend screening for antiphospholipid antibodies (APLAs) [Grade 1A]. For women with these pregnancy complications who test positive for APLAs and have no history of venous or arterial thrombosis, we recommend antepartum administration of prophylactic or intermediate-dose UFH or prophylactic LMWH combined with aspirin (Grade 1B). We recommend that the decision about anticoagulant management during pregnancy for pregnant women with mechanical heart valves include an assessment of additional risk factors for thromboembolism including valve type, position, and history of thromboembolism (Grade 1C). While patient values and preferences are important for all decisions regarding antithrombotic therapy in pregnancy, this is particularly so for women with mechanical heart valves. For these women, we recommend either adjusted-dose bid LMWH throughout pregnancy (Grade 1C), adjusted-dose UFH throughout pregnancy (Grade 1C), or one of these two regimens until the thirteenth week with warfarin substitution until close to delivery before restarting LMWH or UFH) [Grade 1C]. However, if a pregnant woman with a mechanical heart valve is judged to be at very high risk of thromboembolism and there are concerns about the efficacy and safety of LMWH or UFH as dosed above, we suggest vitamin K antagonists throughout pregnancy with replacement by UFH or LMWH close to delivery, after a thorough discussion of the potential risks and benefits of this approach (Grade 2C). (CHEST 2008; 133:844S–886S)

OBJECTIVE: To determine maternal and perinatal outcome in women with severe preeclampsia at !26 weeks according to gestational age at the onset of expectant management and the presence of severe fetal growth restriction (!5th percentile). STUDY DESIGN: Fifty-one patients (53 fetuses; 2 twins) were retrospectively studied. RESULTS: Median prolongation was 7 days (2-55). Maternal morbidity rate was 43%. Perinatal survival rate was 42%. Severe fetal growth restriction complicated 17 fetuses (33%). There were no perinatal survivors in those managed at !24 weeks (n=12). For those at 24-246/7 and 25-256/7 weeks, the perinatal survival rates were 50% and 57%, respectively, and in the presence of severe fetal growth restriction 0% and 30%, respectively. CONCLUSION: Perinatal outcome in severe preeclampsia in the midtrimester is dependent on gestational age and/or the presence of severe fetal growth restriction. Given the high maternal morbidity and the extremely low perinatal survival rates, we do not recommend expectant management before 24 weeks and/or in those with severe fetal growth restriction at any gestational age!26 weeks.

Preeclampsia is a hypertensive, multi-system disorder of pregnancy whose etiology remains unknown. Although management is evidence-based, preventative measures/screening tools are lacking, treatment remains symptomatic, and delivery remains the only cure. Past hypotheses/ scientific contributions have influenced current understanding of preeclampsia pathophysiology and guided management strategies and classification criteria. To provide insight into how past hypotheses/scientific contributions have shaped current practice trends, this paper provides a historical overview of preeclampsia-eclampsia.

The gestational period serves as a natural stress test that can be used to predict future cardiovascular health risks of female patients. Recent evidence confirms that mothers with hypertensive pregnancies have higher cardiovascular disease (CVD) risks compared to other women of similar age. In women with preeclampsia, those delivering before 37 weeks of gestation and mothers with recurring preeclampsia in subsequent pregnancies carry the greater risks. These sex-specific risks are of similar magnitude to traditional CVD risk factors, such as smoking and obesity. Unfortunately, none of the commonly used CVD risk stratification models make use of these sex-specific markers, which can powerfully predict future CVD outcomes. Because women have historically posed a greater diagnostic challenge than men in assessing CVD risks, better models for risk stratification in this sex group are needed. A history of hypertension in pregnancy should be included as a variable in cardiovascular risk stratification. In addition, screening women for a history of preeclampsia should become routine practice, with greater emphasis placed on therapies to modify adverse outcomes for these higher-risk women.

Objective: To investigate the relationships of psychological stress, preeclampsia/gestational hypertension symptoms, confidence in self-monitoring, well-being, and perceived social support with preeclampsia/gestational hypertension disease progression in outpatient women. Women with mild and severe preeclampsia/gestational hypertension were compared for differences in these variables. Design: A retrospective, correlational, and comparative design. Setting: Postpartum units of three urban hospitals in Philadelphia, Pennsylvania. Participants: One hundred postpartum women with preeclampsia/gestational hypertension. Main Outcome Measures: Psychological stress measured by the Perceived Stress Scale, preeclampsia/gestational hypertension symptoms by the Preeclampsia/ Gestational Hypertension Checklist, confidence in self-monitoring by the Self-Confidence in Self-Monitoring Scale, well-being by the Index of Well-Being, and social support by the Interpersonal Support Evaluation List. Results: Women with worsening/severe preeclampsia/gestational hypertension reported a significantly higher number of symptoms than women with mild preeclampsia/gestational hypertension(p = .02). Psychological stress was significantly higher (p = .04) in women with worsening/severe preeclampsia/gestational hypertension. There were no differences in well-being, self-confidence in self-monitoring,or perceived social support between women with mild preeclampsia/gestational hypertension and those with worsening preeclampsia/gestational hypertension. Conclusion: Worsening/severe preeclampsia/gestational hypertension was associated with increasing psychological stress and a higher number of preeclampsia/gestational hypertension symptoms.

Peripartum cardiomyopathy (PPCM) is a relatively rare idiopathic form of heart failure that affects women during the last months of pregnancy or the first months after delivery. The aetiology and pathophysiological mechanisms of this disease are poorly characterised and incompletely understood. Diagnosis remains a challenge, as PPCM symptoms vary and may mimic those commonly experienced by women during pregnancy and postpartum due to normal physiological changes that occur during this period. The clinical course varies between complete recovery to rapid progression to end stage heart failure and even death. Standard heart failure treatment, with adjustments for women who are pregnant or lactating, is the treatment of choice. Disease specific therapeutic strategies, including prolactin blockade, show promise. National and international registries and collaborative research efforts are warranted to characterise this disease better and to develop novel treatments that can improve outcomes.

OBJECTIVE: To estimate whether maternal obesity was associated with an increased risk for postpartum hemorrhage more than 1,000 mL and whether there was an association between maternal obesity and causes of postpartum hemorrhage and mode of delivery. METHODS: A population-based cohort study including 1,114,071 women with singleton pregnancies who gave birth in Sweden from January 1, 1997 through December 31, 2008, who were divided into six body mass index (BMI) classes. Obese women (class I–III) were compared with normal-weight women concerning the risk for postpartum hemorrhage after suitable adjustments. The use of heparin-like drugs over the BMI strata was analyzed in a subgroup. RESULTS: There was an increased prevalence of postpartum hemorrhage over the study period associated primarily with changes in maternal characteristics. The risk of atonic uterine hemorrhage increased rapidly with increasing BMI. There was a twofold increased risk in obesity class III (1.8%). No association was found between postpartum hemorrhage with retained placenta and maternal obesity. There was an increased risk for postpartum hemorrhage for women with a BMI of 40 or higher (5.2%) after normal delivery (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.04 –1.45]) compared with normal-weight women (4.4%) and even more pronounced (13.6%) after instrumental delivery (OR 1.69, 95% CI 1.22–2.34) compared with normal-weight women (8.8%). Maternal obesity was a risk factor for the use of heparin-like drugs (OR 2.86, 95% CI 2.22–3.68). CONCLUSION: The increased risk for atonic postpartum hemorrhage in the obese group has important clinical implications, such as considering administration of prophylactic postpartum uterotonic drugs to this group.

OBJECTIVE: The objective of the study was to determine perinatal outcome and maternal morbidities based on gestational age (GA) at the onset of expectant management in severe preeclampsia at less than 27 weeks. STUDY DESIGN: This was a retrospective analysis of outcome in patients with severe preeclampsia. Forty-six patients (51 fetuses) with severe preeclampsia at less than 27 weeks were studied. Corticosteroids were administered beyond 23 weeks. Perinatal and maternal complications (a composite maternal morbidities including HELLP (hemolysis, elevated liver enzymes, and low platelet count ) syndrome, pulmonary edema, eclampsia, and renal insufficiency were analyzed. RESULTS: Four patients had multifetal gestations (1 triplet, 3 twins). Median days of prolongation was 6 (range 2-46). Overall perinatal survival was 29 of 51 (57%). Birthweights of 27 (53%) were less than 10%, and 18 (35%) were less than 5%. There were no perinatal survivors in those with a GA less than 23 weeks, at 23 to 23 6/7 weeks, 2 of 10 (20%) survived, and both reached 26 weeks at delivery. For those at 24 to 24 6/7, 25 to 25 6/7, and 26 to26 6/7 weeks, the perinatal survival rates were 5 of 7 (71%), 13 of 17 (76%), and 9 of 10 (90%), respectively; but rates of respiratory complications were high. There were no maternal deaths, but overall maternal morbidity was 21 of 46 (46%), but was 9 of 14 (64%) in those at less than 24 weeks. CONCLUSION: Perinatal outcome in severe preeclampsia in the midtrimester is dependent on GA at onset of expectant management and GA at delivery. Given the high maternal morbidity and extremely low perinatal survival in expectant management at less than 24 weeks, termination of pregnancies should be offered after extensive counseling.

Pulmonary embolism (PE) is the leading cause of maternal mortality in the developed world. Mortality from PE in pregnancy might be related to challenges in targeting the right population for prevention, ensuring that diagnosis is suspected and adequately investigated, and initiating timely and best possible treatment of this disease. Pregnancy is an example of Virchow’s triad: hypercoagulability, venous stasis, and vascular damage; together these factors lead to an increased incidence of venous thromboembolism. This disorder is often suspected in pregnant women because some of the physiological changes of pregnancy mimic its signs and symptoms. Despite concerns for fetal teratogenicity and oncogenicity associated with diagnostic testing, and potential adverse eff ects of pharmacological treatment, an accurate diagnosis of PE and a timely therapeutic intervention are crucial. Appropriate prophylaxis should be weighed against the risk of complications and off ered according to risk stratifi cation.

OBJECTIVE: To quantify the incidence of severe maternal morbidity in Scotland and determine the feasibility of doing so.
DESIGN: Prospective observational study.
SETTING: All 22 consultant led maternity units in Scotland, between 1 October 2001 and 30 September 2002.
POPULATION: Women during pregnancy and the puerperium.
METHODS: Definitions for 13 categories of severe maternal morbidity were developed from published work. Recruitment of maternity units, and training of staff, took place at a national meeting. Each month, every unit reported cases meeting the agreed definitions, the category of incident and date. Data were collated centrally and analysed to determine the frequency of incidents. The number of maternal deaths occurring in Scotland over the same period was obtained from the Confidential Enquiry into Maternal Deaths.
MAIN OUTCOME MEASURES: Number and rate of defined events being reported. A subjective view of the feasibility of collecting national data routinely.
RESULTS: Severe morbidity was reported in 196 women, out of 51,165 deliveries in Scotland (rate 3.8 per 1000 deliveries). Thirty percent of cases fell into more than one defined category. Major obstetric haemorrhage accounted for 50% of events. Only a third of identified patients were admitted to intensive care units. Four relevant maternal deaths occurred.
CONCLUSIONS: Categories of severe maternal morbidity can be defined and may provide a useful measure of the quality of maternity services, particularly in developed countries where maternal mortality is very rare. It appears feasible to set up a national reporting system for maternal morbidity, as well as mortality.

Objective: The purpose of this study was to assess recurrence rates of preeclampsia and neonatal outcomes in women with a history of preeclampsia that required preterm delivery. Study Design: Five hundred women with previous preeclampsia that required delivery at <37 weeks' gestation were followed prospectively. Results: Preeclampsia reoccurred in 117 women (23%). Predictive factors included black (odds ratio [OR], 2.29; 95% confidence interval [CI], 1.16–4.53) or Asian (OR, 2.98; 95% CI, 1.33–6.59) ethnicity, enrollment systolic blood pressure of >130 mm Hg (OR, 2.89; 95% CI, 1.52–5.50), current antihypertensive use (OR, 6.39; 95% CI, 2.38–17.16), and proteinuria of ≥2+ on enrollment urinalysis (OR, 12.35; 95% CI, 3.45–44.21). Women who previously delivered at <34 weeks' gestation were more likely to deliver preterm again (29% vs 17%; relative risk, 1.69; 95% CI, 1.19–2.40) than were those women with previous delivery between 34 and 37 weeks'gestation. Conclusion: Although this study confirms that women with previous preeclampsia that required early delivery are at high risk of the development of preeclampsia, the study identifies risk factors for recurrence and illustrates that women with previous preeclampsia are at greater risk of adverse neonatal outcome.

OBJECTIVE: Cesarean section (CS) rates continue to rise throughout the developed world. The aim of this study was to highlight variations in obstetric populations and practices and to identify variations in CS rates in different institutions. STUDY DESIGN: Data from 9 institutional cohorts (total, 47,402; range, 1962-7985) from 9 different countries were examined using a 10-group classification system based on 4 characteristics of every pregnancy, namely single/multiple, nulliparity/multiparity, multiparity with CS scar, spontaneous/induced labor onset and term (
37 weeks) gestation. RESULTS: Overall CS rates correlated with CS rates in singleton cephalic nullipara (r
0.992; P  .001). Whereas CS rates in induced labor were similar, greatest institutional variation were seen in spontaneously laboring multiparas (6.7-fold difference) and nulliparas (3.7- fold difference). CONCLUSION: Ten-group analysis of international obstetric cesarean practice identifies wide variations in women in spontaneous cephalic term labor, a low-risk cohort amenable to effective intrapartum corrective intervention. Key words: cesarean section, classification system, labor, pregnancy

OBJECTIVE: To identify and estimate prevalence rates of maternal morbidities by pregnancy outcome and selected covariates during the antepartum, intrapartum, and postpartum periods in a defined population of pregnant women.
METHODS: We used electronic data systems of a large, vertically integrated, group-model health maintenance organization (HMO) to develop an algorithm that searched International Classification of Diseases, 9th Revision, Clinical Modification, codes for 38 predetermined groups of pregnancy-related complications among women enrollees of this HMO between January 1, 1998, and December 31, 2001.
RESULTS: We identified 24,481 pregnancies among 21,011 women. Although prevalence and type of morbidity varied by pregnancy outcome, overall, 50% of women had at least one complication. The most common complications were anemia (9.3%), urinary tract infections (9.0%), mental health conditions (9.0%), hypertensive disorders (8.5%), and pelvic and perineal trauma (7.0%).
CONCLUSION: A range of mild-to-severe pregnancy complications were identified using linked inpatient and outpatient databases. The most common complications we found usually do not require hospitalization so would be missed in studies that use only hospitalization data. Our data allowed examination of a broad scope of conditions and severity. These findings increase our understanding of the extent of maternal morbidity.
LEVEL OF EVIDENCE: II.

OBJECTIVE: To estimate the effect of low-dose aspirin started in early pregnancy on the incidence of preeclampsia and intrauterine growth restriction (IUGR). DATA SOURCES: A systematic review and meta-analysis were performed through electronic database searches (PubMed, Cochrane, Embase). METHODS OF STUDY SELECTION: Randomized controlled trials of pregnant women at risk of preeclampsia who were assigned to receive aspirin or placebo (or no treatment) were reviewed. Secondary outcomes included IUGR, severe preeclampsia and preterm birth. The effect of aspirin was analyzed as a function of gestational age at initiation of the intervention (16 weeks of gestation or less, 16 weeks of gestation or more). TABULATION, INTEGRATION,
AND RESULTS: Thirty-four randomized controlled trials met the inclusion criteria, including 27 studies (11,348 women) with follow-up for the outcome of preeclampsia. Low-dose aspirin started at 16 weeks or earlier was associated with a significant reduction in preeclampsia (relative risk [RR] 0.47, 95% confidence interval [CI] 0.34–0.65, prevalence in 9.3% treated compared with 21.3% control) and IUGR (RR 0.44, 95% CI 0.30–0.65, 7% treated compared with 16.3% control), whereas aspirin started after 16 weeks was not (preeclampsia: RR 0.81, 95% CI 0.63–1.03, prevalence in 7.3% treated compared with 8.1% control;
IUGR: RR 0.98, 95% CI 0.87–1.10, 10.3% treated compared with 10.5% control). Low-dose aspirin started at 16 weeks or earlier also was associated with a reduction in severe preeclampsia (RR 0.09, 95% CI 0.02– 0.37, 0.7% treated compared with 15.0% control), gestational hypertension (RR 0.62, 95% CI 0.45– 0.84, 16.7% treated compared with 29.7% control), and preterm birth (RR 0.22, 95% CI 0.10–0.49, 3.5% treated compared with 16.9% control). Of note, all studies for which aspirin had been started at 16 weeks or earlier included women identified to be at moderate or high risk for preeclampsia. CONCLUSION: Low-dose aspirin initiated in early pregnancy is an efficient method of reducing the incidence of preeclampsia and IUGR.

Management of massive, life-threatening primary postpartum hemorrhage in the labor and delivery service is a challenge for the clinical team and hospital transfusion service. Because severe postpartum obstetrical hemorrhage is uncommon, its occurrence can result in emergent but variable and nonstandard requests for blood products. The implementation of a standardized massive transfusion protocol for the labor and delivery department at our institution after a maternal death caused by amniotic fluid embolism is described. This guideline was modeled on a existing protocol used by the trauma service mandating emergency release of 6 units of group O D- red cells (RBCs), 4 units of fresh frozen or liquid plasma, and 1 apheresis unit of platelets (PLTs). The 6:4:1 fixed ratio of uncrossmatched RBCs, plasma, and PLTs allows the transfusion service to quickly provide blood products during the acute phase of resuscitation and allows the clinical team to anticipate and prevent dilutional coagulopathy. The successful management of three cases of massive primary postpartum hemorrhage after the implementation of our new massive transfusion protocol in the maternal and fetal medicine service is described.

Preeclampsia and stroke are significantly related, both pathologically and temporally (across the life span) in women. Cerebrovascular events can complicate preeclampsia, and can also manifest later in life. A history of preeclampsia is associated with long-term risk for hypertension, stroke, and heart disease. Cerebrovascular complications occur in only a small proportion of women with severe preeclampsia, but with high morbidity and mortality. Endothelial dysfunction and impaired cerebral autoregulation, and severe hypertension in the setting of preeclampsia are likely the cause of many strokes during pregnancy. The relationship between preeclampsia and stroke involves shared risk factors for both disorders, including chronic endothelial dysfunction and increased risk for long-term hypertension following preeclampsia (one of the major risk factors for stroke). This overlap provides insights into underlying pathophysiology and potential preventive strategies for both preeclampsia and stroke. For example, aspirin may prevent both disorders. The current review will describe the current data regarding these relationships and suggest future research to investigate remaining knowledge gaps. These are important topics for neurologists, who are likely to be involved with the care of severely ill preeclamptic patients with neurologic complications, as well as women at increased risk of stroke due to a history of preeclampsia. doi:10.4061/2011/858134

OBJECTIVE: This investigation aimed to identify pregnancy complications and risk factors for women who experienced severe maternal morbidity during the delivery hospitalization and to estimate severe maternal morbidity rates. STUDY DESIGN: We used the National Hospital Discharge Survey for 1991-2003 to identify delivery hospitalizations with maternal diagnoses and procedures that indicated a potentially life-threatening diagnosis or life-saving procedure. RESULTS: For 1991-2003, the severe maternal morbidity rate in the United States was 5.1 per 1000 deliveries. Most women who were classified as having severe morbidity had an ICD-9-CM code for transfusion, hysterectomy, or eclampsia. Severe morbidity was more common at the extremes of reproductive age and for black women, compared with white women. CONCLUSION: Severe maternal morbidity is 50 times more common than maternal death. Understanding these experiences of these women potentially could modify the delivery of care in healthcare institutions and influence maternal health policy at the state and national level.

Objective: The objective of this study was to estimate the effects of low and high gestational weight gain, in different maternal Body Mass Index (BMI) classes, on obstetric and neonatal outcomes. Method: A prospective population-based cohort study of 245,526 singleton termpregnancies.Women were grouped in five categories of BMI and in three gestational weight gain categories; b8 kg (low weight gain), 8—16 kg and N16 kg (high weight gain). Obstetric and neonatal outcomes were evaluated after adjustments for maternal age, parity, smoking, year of birth. Result: Obese women with low gestational weight gain had a decreased risk for the following outcomes (adjusted odds ratio; 95% confidence interval): preeclampsia (0.52; 0.42—0.62), cesarean section (0.81; 0.73—0.90), instrumental delivery (0.75; 0.63—0.88), and LGA births (0.66; 0.59—0.75). There was a 2-fold increased risk for preeclampsia and LGA infants among average and overweight women with excessive weight gain. High gestational weight gain increased the risk for cesarean delivery in all maternal BMI classes. Conclusion: The effects of high or low gestational weight gain differ depending on maternal BMI and the outcome variable studied. Obese women may benefit from a low weight gain during pregnancy.

OBJECTIVE: To establish optimal gestational weight gain for each maternal body mass index (BMI) category based on significant risk estimates of adverse maternal and fetal outcome. METHODS: The study population consisted of 298,648 singleton pregnancies delivered in Sweden between January 1, 1994, and December 31, 2004. The number of individuals in each weight gain class was compared with the number of individuals in all other weight gain classes in the same BMI group with regard to adverse maternal and fetal outcome. Odds ratios were calculated after suitable adjustments. RESULTS: The optimal gestational weight gain in women by prepregnancy BMI was 9–22 lb (4–10 kg) for BMI less than 20; 5–22 lb (2–10 kg) for BMI 20–24.9; less than 20 lb (less than 9 kg) for BMI 25–29.9; and less than 13 lb (less than 6 kg) for BMI of 30 or more. CONCLUSION: The gestational weight gain limits for BMI categories determined in this large populationbased cohort study from Swedish Medical Registers showed that a decreased risk of adverse obstetric and neonatal outcomes was associated with lower gestational weight gain limits than was earlier recommended, especially among obese women.

OBJECTIVE: The purpose of this study was to examine the association between gestational weight gain (GWG) in a woman’s first and second pregnancies. STUDY DESIGN: We conducted a retrospective observational cohort study of 27,771 women with their first and second births in North Carolina’s Pregnancy Nutrition Surveillance System database from 1996-2004. GWG was categorized as inadequate, appropriate, or excessive, according to 2009 Institute of Medicine guidelines. Covariate adjusted polytomous logistic regression was used to test the association between GWG category in the first and second pregnancy. RESULTS: Compared with women with appropriate GWG in their first pregnancy, women with excessive GWG in their first pregnancy had an odds ratio of 2.6 (95% confidence interval, 2.4 –2.7) for excessive GWG in their second pregnancy. Women with inadequate GWG in their first pregnancy were similarly likely to repeat this category in their subsequent pregnancy. CONCLUSION: GWG category in a woman’s first pregnancy is a significant predictor of GWG category in her subsequent pregnancy.

OBJECTIVE: Numerous studies in the U.S. and elsewhere have reported an increased risk of gestational diabetes mellitus (GDM) among women who are overweight or obese compared with lean or normal-weight women. Despite the number and overall consistency of studies reporting a higher risk of GDM with increasing weight or BMI, the magnitude of the association remains uncertain. This meta-analysis was conducted to better estimate this risk and to explore differences across studies. RESEARCH DESIGN AND METHODS: We identified studies from three sources: 1) a PubMed search of relevant articles published between January 1980 and January 2006, 2) reference lists of publications selected from the PubMed search, and 3) reference lists of review articles on obesity and maternal outcomes published between January 2000 and January 2006. We used a Bayesian model to perform the meta-analysis and meta-regression. We included cohort-designed studies that reported obesity measures reflecting pregnancy body mass, that had a normal-weight comparison group, and that presented data allowing a quantitative measurement of risk. RESULTS: Twenty studies were included in the meta-analysis. The unadjusted ORs of developing GDM were 2.14 (95% CI 1.82–2.53), 3.56 (3.05– 4.21), and 8.56 (5.07–16.04) among overweight, obese, and severely obese compared with normal-weight pregnant women, respectively. The meta-regression analysis found no evidence that these estimates were affected by selected study characteristics (publication date, study location, parity, type of data collection [retrospective vs. prospective], and prevalence of GDM among normal-weight women). CONCLUSIONS: Our findings indicate that high maternal weight is associated with a substantially higher risk of GDM.

PURPOSE OF REVIEW: This review will summarize the latest publications on the causes, prevention and treatment of maternal collapse during pregnancy and the postpartum period. It will also explore some future trends particularly in the area of education and team working.
RECENT FINDINGS: Active management of the third stage of labour has been shown to decrease the incidence of postpartum haemorrhage. Inadequate or prolonged resuscitation following major postpartum haemorrhage can lead to myocardial damage. Guidelines that are followed and the use of drills and simulators may increase effective team working and lead to earlier recognition and treatment of maternal collapse. Some cases of amniotic fluid embolism resemble anaphylaxis and should be treated as such. Important evidence-based guidelines on the management of antithrombolytic prophylaxis and the management of pulmonary embolism have recently been published, which should help clinicians clarify their medical care plans. New resuscitation guidelines in the UK will probably mean that all healthcare workers (including obstetricians and midwives) will need appropriate training every year.
SUMMARY: Understanding the causes of maternal collapse, its early recognition and prompt resuscitation should decrease both maternal and fetal morbidity and mortality. There is increasing evidence that effective preventative measures and improved multidisciplinary team working may have an important impact on maternal and fetal well-being.

OBJECTIVE: The purpose of this study was to define patterns of morbidity that are experienced by women in the postpartum period who seek care in the emergency department within 42 and 100 days of discharge. STUDY DESIGN: We conducted a retrospective examination of discharge diagnosis codes and descriptions for emergency department visits and analyzed temporal patterns of both emergency department visits and hospital readmissions. RESULTS: During 2007, 222,084 patients delivered in Hospital Corporation of America facilities in the United States. Among these women, there were 10,751 emergency department visits within 42 days of delivery (4.8%). Fifty-eight percent of the patients were seen for conditions that were related to pregnancy; 42% of the patients were seen for conditions unrelated to pregnancy. Fifty percent of patients in the postpartum period who were seen either in the emergency department (21,833 patients) or readmitted (5190 patients) during both 2007 and 2008 had this encounter within 10 days of discharge. CONCLUSION: The scheduling and content of traditional postpartum education and clinical visits appear poorly suited to the prevention of puerperal morbidity.

The death of a mother during or after childbirth is one of the most tragic events in medicine. We have identified 10 specific recurrent errors that account for a disproportionate share of maternal deaths, primarily related to pulmonary embolism, severe preeclampsia, cardiac disease, and postpartum hemorrhage. Attention to these principles and the development and adoption of local or regional clinical protocols that address these issues will help reduce the likelihood and effect of error and of maternal mortality.

INTRODUCTION: The 2000-2002 triennial UK Report on Confidential Enquiries into Maternal Deaths concluded that over 50% of maternal deaths involved substandard care and that many could have been prevented. Catastrophic events leading to cardio-respiratory arrest may necessitate the resuscitation of pregnant women in various hospital locations. This study was designed to evaluate knowledge about resuscitation of parturients among anesthesiologists, obstetricians and emergency physicians.
METHODS: A 12-question survey was distributed anonymously to residents and faculty in the anesthesia (ANES), obstetrics (OB), and emergency medicine (EM) departments at Stanford University Medical Center/Lucile Packard Children's Hospital, Stanford, California. Questions were designed to elicit knowledge deficiencies in four critical areas: need for left uterine displacement (LUD), advanced cardiac life support algorithms (ACLS), physiologic changes of pregnancy (PHYS), and the recommendation to perform cesarean delivery in parturients (>20 weeks gestation) after 4-5 min of unsuccessful resuscitation for cardiac arrest (5CD).
RESULTS: In total, 74/75 physicians (43% ANES, 37% OB, and 20% EM) completed the test. ANES scored highest in overall test scores, and in knowledge of PHYS (P<0.05). Scores for LUD and 5CD were similar among groups, but 25-40% of these questions were answered incorrectly. In the ACLS category, the EM group scored highest (93%).
CONCLUSION: We conclude that knowledge of important basic concepts, including the need for LUD and the potential benefit of early cesarean delivery during cardiac arrest, is inadequate among all three specialties. All three departments should provide ACLS physician training with emphasis on the special considerations for parturients.

OBJECTIVES: This study sought to determine the prevalence of maternal morbidity during labor and delivery in the United States.
METHODS: Analyses focused on National Hospital Discharge Survey data available for women giving birth between 1993 and 1997.
RESULTS: The prevalence of specific types of maternal morbidity was low, but the burden of overall morbidity was high. Forty-three percent of women experienced some type of morbidity during their delivery hospitalization. Thirty-one percent (1.2 million women) had at least 1 obstetric complication or at least 1 preexisting medical condition.
CONCLUSIONS: Maternal morbidity during delivery is frequent and often preventable. Reducing maternal morbidity is a national health objective, and its monitoring is key to improving maternal health.

Objectives: This study sought to determine the prevalence of maternal morbidity during labor and delivery in the United States. Methods: Analyses focused on National Hospital Discharge Survey data available for women giving birth between 1993 and 1997. Results: The prevalence of specific types of maternal morbidity was low, but the burden of overall morbidity was high. Forty-three percent of women experienced some type of morbidity during their delivery hospitalization. Thirty-one percent (1.2 million women) had at least 1 obstetric complication or at least 1 preexisting medical condition. Conclusions: Maternal morbidity during delivery is frequent and often preventable. Reducing maternal morbidity is a national health objective, and its monitoring is key to improving maternal health.

OBJECTIVE: To estimate the effect of maternal habitus on detection of fetuses with major structural anomalies during second-trimester standard and targeted ultrasound examinations. METHODS: This was a retrospective cohort study of pregnancies 18 to 24 weeks that underwent ultrasonography over a 5-year period. An anomalous fetus was considered detected if a major abnormality of the relevant organ system was identified, regardless of the anticipated ultrasound detection. Anomalies were verified using a prospectively maintained database. Body mass index (BMI) was based on weight at first prenatal visit. RESULTS: There were 10,112 standard examinations in low-risk pregnancies and 1,098 targeted examinations in pregnancies with either high-risk indications or with an abnormality detected during standard ultrasonography. Detection of anomalous fetuses decreased with increasing BMI. For normal BMI, overweight, and class I, II, and III obesity, detection with standard ultrasonography was 66%, 49%, 48%, 42%, and 25%, respectively, and with targeted ultrasonography, 97%, 91%, 75%, 88%, and 75%, respectively, both P<.03. Residual anomaly risk after a normal ultrasound examination increased with increasing BMI, from 0.4% among women of normal BMI to 1.0% among obese women, P
.001. Anomaly detection was lower among women with pregestational diabetes than in those with other high-risk indications, 38% compared with 88% respectively, P<.001. CONCLUSION: With increasing maternal BMI, we found decreased detection of anomalous fetuses with either standard or targeted ultrasonography, a difference of at least 20% when women of normal BMI were compared with obese women. Anomaly detection was even less in pregnancies complicated by pregestational diabetes. Counseling may need to be modified to reflect the limitations of ultrasonography in obese women.

BACKGROUND: All cases of obstetric hysterectomies that were performed in our hospital during a seven-year study period were reviewed in order to evaluate the incidence, indications, risk factors, and complications associated with emergency obstetric hysterectomy.
METHODS: Medical records of 45 patients who had undergone emergency hysterectomy were scrutinized and evaluated retrospectively. Maternal age, parity, gestational age, indication for hysterectomy, the type of operation performed, estimated blood loss, amount of blood transfused, complications, and hospitalization period were noted and evaluated. The main outcome measures were the factors associated with obstetric hysterectomy as well as the indications for the procedure.
RESULTS: During the study period there were 32,338 deliveries and 9,601 of them (29.7%) were by cesarean section. In this period, 45 emergency hysterectomies were performed, with an incidence of 1 in 2,526 vaginal deliveries and 1 in 267 cesarean sections. All of them were due to massive postpartum hemorrhage. The most common underlying pathologies was placenta accreta (51.1%) and placenta previa (26.7%). There was no maternal mortality.
CONCLUSIONS: Obstetric hysterectomy is a necessary life-saving procedure. Abnormal placentation is the leading cause of emergency hysterectomy when obstetric practice is characterized by a high cesarean section rate. Therefore, every attempt should be made to reduce the cesarean section rate by performing this procedure only for valid clinical indications

OBJECTIVE: To compare the outcomes and costs associated with primary cesarean births with no labor (planned cesareans) to vaginal and cesarean births with labor (planned vaginal).
METHODS: Analysis was based on a Massachusetts data system linking 470,857 birth certificates, fetal death records, and birth-related hospital discharge records from 1998 and 2003. We examined a subset of 244,088 mothers with no prior cesarean and no documented prenatal risk. We then divided mothers into two groups: those with no labor and a primary cesarean (planned primary cesarean deliveries-3,334 women) and those with labor and either a vaginal birth or a cesarean delivery (planned vaginal-240,754 women). We compared maternal rehospitalization rates and analyzed costs and length of stay.
RESULTS: Rehospitalizations in the first 30 days after giving birth were more likely in planned cesarean (19.2 in 1,000) when compared with planned vaginal births (7.5 in 1,000). After controlling for age, parity, and race or ethnicity, mothers with a planned primary cesarean were 2.3 (95% confidence interval [CI] 1.74-2.9) times more likely to require a rehospitalization in the first 30 days postpartum. The leading causes of rehospitalization after a planned cesarean were wound complications (6.6 in 1,000) (P<.001) and infection (3.3 in 1,000). The average initial hospital cost of a planned primary cesarean of US dollars 4,372 (95% C.I. US dollars 4,293-4,451) was 76% higher than the average for planned vaginal births of US dollars 2,487 (95% C.I. US dollars 2,481-2,493), and length of stay was 77% longer (4.3 days to 2.4 days).
CONCLUSION: Clinicians should be aware of the increased risk for maternal rehospitalization after cesarean deliveries to low-risk mothers when counseling women about their choices.
LEVEL OF EVIDENCE: II.

Intracranial hemorrhage (ICH) from an intracranial aneurysm or arteriovenous malformation is a grave complication of pregnancy and is responsible for 5 to 12% of all maternal deaths. We critically analyzed 154 cases of verified ICH during pregnancy from an identified intracranial lesion, including 2 patients treated at our institution and 152 cases previously reported in the literature in English. Aneurysms were responsible for ICH in 77% of patients, and arteriovenous malformations in 23%. Hemorrhage occurred antepartum in 92% of patients and postpartum in 8%. Women with angiomatous hemorrhage were younger than those with aneurysmal hemorrhage; however, in contrast to previous reports, we found no differences between angiomatous and aneurysmal hemorrhage with respect to parity or gestational age at the time of the initial hemorrhage. Hypertension and/or albuminuria were present at some time during the pregnancy in 34% of patients with documentation, which sometimes made it difficult to differentiate angiomatous or aneurysmal ICH from that associated with eclampsia. In a logistic regression analysis, surgical management of aneurysms, but not arteriovenous malformations, was associated with significantly lower maternal and fetal mortality, independent of other covariants. For those patients with a lesion not operated on, cesarean delivery afforded no better maternal or fetal outcome than did vaginal delivery. We conclude that the decision to operate after ICH during pregnancy should be based upon neurosurgical principles, whereas the method of delivery should be based upon obstetrical considerations. The perioperative and anesthetic management of the pregnant patient with a neurosurgical complication is discussed.

Impediments to and progress toward valid and reliable international quality comparisons at the diagnosis or case type level are identified and discussed. The need for uniformity in each of the following is established: (1) international clinical data set, (2) definitions of clinical data elements and (3) data collection practices. The need to establish a clinically adequate international data base is discussed and action steps are identified.

OBJECTIVE: To identify factors associated with severity of postpartum hemorrhage among characteristics of women and their delivery, the components of initial postpartum hemorrhage management, and the organizational characteristics of maternity units. METHODS: This population-based cohort study included women with postpartum hemorrhage due to uterine atony after vaginal delivery in 106 French hospitals between December 2004 and November 2006 (N
4,550). Severe postpartum hemorrhage was defined by a peripartum change in hemoglobin of 4 g/dL or more. A multivariable logistic model was used to identify factors independently associated with postpartum hemorrhage severity. RESULTS: Severe postpartum hemorrhage occurred in 952 women (20.9%). In women with postpartum hemorrhage, factors independently associated with severity were: primiparity; previous postpartum hemorrhage; previous cesarean delivery; cervical ripening; prolonged labor; and episiotomy; and delay in initial care for postpartum hemorrhage. Also associated with severity was 1) administration of oxytocin more than 10 minutes after postpartum hemorrhage diagnosis: 10–20 minutes after, proportion with severe postpartum hemorrhage 24.6% compared with 20.5%, adjusted OR 1.38, 95% CI 1.03–1.85; more than 20 minutes after, 31.8% compared with 20.5%, adjusted OR 1.86, CI 1.45–2.38; 2) manual examination of the uterine cavity more than 20 minutes after (proportion with severe postpartum hemorrhage 28.2% versus 20.7%, adjusted OR 1.83, 95% CI 1.42–2.35); 3) call for additional assistance more than 10 minutes after (proportion with severe postpartum hemorrhage 29.8% versus 24.8%, adjusted OR 1.61, 95% CI 1.23–2.12 for an obstetrician, and 35.1% compared with 29.9%, adjusted OR 1.51, 95% CI 1.14–2.00 for an anesthesiologist); 4) and delivery in a public non-university hospital. Epidural analgesia was found to be a protective factor against severe blood loss in women with postpartum hemorrhage. CONCLUSION: Aspects of labor, delivery, and their management; delay in initial care; and place of delivery are independent risk factors for severe blood loss in women with postpartum hemorrhage caused by atony. (Obstet Gynecol 2011;117:21–31) DOI: 10.1097/AOG.0b013e318202c845

Induction of labor has become routine practice in perinatal units across the United States, with rates reaching a high of 21.2% of births in 2003-2004. This article describes the process our institution used to standardize the criteria for scheduling inductions. Specifically, we aimed to increase the consistency in practice for scheduling and performing elective inductions, including mandating gestational age of 39 completed weeks, ensuring cervical ripeness, and disallowing the use of cervical ripening agents. The nurses’ participation, from planning to implementation, was critical in the success of this evidence-based practice change.

OBJECTIVE: The purpose of this study was to evaluate the effect of pregravid obesity and gestational diabetes mellitus (GDM) on the longitudinal accretion and distribution of adipose tissue in pregnancy. STUDY DESIGN: Women with normal glucose tolerance and GDM were evaluated before conception, early (12-14 weeks) and late (33-36 weeks) in gestation. Fat mass, lean body mass, and percent body fat were assessed longitudinally with hydrodensitometry. Serial biceps, triceps, subscapular, iliac, costal, mid thigh, and lower thigh skinfold measurements quantified the changes in fat mass distribution. Pregravid obesity was defined as >25% body fat. RESULTS: Subjects included 19 patients with GDM (5 lean women, 14 obese women), and 33 patients with normal glucose tolerance (controls; 12 lean women, 21 obese women). GDM and control subjects were similar in pregravid percent body fat (29.6% vs 27.9%, P = .47) and fat mass (20.8 kg vs 18.2 kg, P = .37). Values for subjects with GDM and controls were also similar in terms of percent body fat, fat mass, and weight gained (change in percent body fat,
0.7% vs 1.9% [P = .07]; change in fat mass, 3.8 kg vs 5.0 kg [P = .08]; change in weight, 12.0 kg vs 13.2 kg [P = .35]). Lean subjects gained more percent body fat compared with obese subjects (change in percent body fat, 3.3% vs 0.1% [P = .004]) but gained similar amounts of fat mass (change in fat mass, 4.7 kg vs 4.2 kg [P = .58]), lean body mass (7.6 kg vs 8.8 kg [P = .18]), and weight (change in weight, 12.3kg vs 13.0 kg [P = .61]) The distribution of adipose tissue that was accumulated as estimated with skinfold measurements was similar between patients with GDM and glucose tolerance (P > .05 for all changes in skinfolds), but significantly different between lean and obese patients (P< .05 for all changes in skinfolds). Lean women gained a predominance of adipose tissue peripherally over that in obese women. CONCLUSION: Lean women accrue significantly more fat mass than obese women, regardless of glucose tolerance. Pregestational obesity rather than GDM influences the distribution of adipose accretion.

Nursing 66(10), 2142–2153. doi: 10.1111/j.1365-2648.2010.05391.x Abstract Aim. This study presents the findings a meta-ethnographic study reporting women’s perceptions and experiences of traumatic birth. Background. Childbirth is viewed by many as a life transition that can bring a sense of accomplishment. However, for some women, birth is experienced as a traumatic event with a minority experiencing post-traumatic stress. A traumatic birth experience can have a significant impact on the physical and emotional well-being of a woman, her infant and family. Data source. The CINAHL, MEDLINE, Scopus and PubMed databases were searched for the period January 1994 to October 2009 using the keywords birth trauma, traumatic birth, qualitative research, birth narrative and birth stories. Review methods. A meta-ethnographic approach was used. Quality appraisal was carried out. An index paper served as a guide in identifying particular findings and comparing them with other findings. This ‘reciprocal translation’ process started witha search for common themes, phrases and metaphors. Results. Ten qualitative studies were included in the final sample. Six major themes were identified: ‘feeling invisible and out of control’, ‘to be treated humanely’, ‘feeling trapped: the reoccurring nightmare of my childbirth experience’, ‘a rollercoaster of emotions’, ‘disrupted relationships’ and ‘strength of purpose: a way to succeed as a mother’. Conclusions. It is evident that a small percentage of women experience a traumatic birth. Although some women who experience a traumatic birth do not necessarily have physical or psychological adverse outcomes, others identify a significant personal impact. Healthcare professionals must recognize women’s need to be involved in decision-making and to be fully informed about all aspects of their labour and birth to increase their sense of control. Keywords: childbirth, meta-ethnography, midwifery, nursing, qualitative study, traumatic birth

STUDY OBJECTIVE: To evaluate the predictive ability of three scoring systems, acute physiology and chronic health evaluation (APACHE II), simplified acute physiology score (SAPS II), and mortality probability models (MPM II) in critically ill obstetric patients compared to a control group of non-obstetric female patients of similar age group (range, 17 to 41 years).
DESIGN: A retrospective medical chart review of obstetric and nonobstetric female patients between 17 and 41 years of age.
SETTING: Two university hospitals.
PATIENTS: Ninety-three obstetric patients and 96 nonobstetric female patients were identified from 12,740 consecutive ICU admissions.
RESULTS: The actual mortality of the obstetric and the nonobstetric group was 10.8% (95% confidence interval [CI], 5.3 to 19.0%) and 12.5% (95% CI, 6.6 to 21.0%), respectively. The observed mortality was not statistically different from the mortality predicted by APACHE II, SAPS II, and MPM II (14.7%, 7.8%, and 9.1% for the obstetric group and 10.9%, 9.0%, and 9.9% for the nonobstetric group). Predictive accuracy was assessed by the c-index, which is equivalent to the area under the receiver operator characteristic (ROC) curve. There were no significant differences in the c-index for APACHE II, SAPS II, and MPM II within or between the obstetric group ([mean +/- SE], 0.93 +/- 0.02, 0.90 +/- 0.04, and 0.91 +/- 0.04, respectively) and the nonobstetric group (0.97 +/- 0.02, 0.95 +/- 0.03, and 0.96 +/- 0.02, respectively).
CONCLUSIONS: We conclude that APACHE II, SAPS II, and MPM II assess the ICU outcome of critically ill obstetric patients as accurately as nonobstetric critically ill female patients of similar age group.

Objective: The purpose of this retrospective cohort study was to review pregnancy outcomes in morbidly obese women who delivered a baby weighing 500 g or more in a large tertiary referral university hospital in Europe. Methods: Morbid obesity was defined as a BMI ≥ 40.0 kg/m2 (WHO). Only women whose BMI was calculated at their first antenatal visit were included. The obstetric outcomes were obtained from the hospital’s computerised database. Results: The incidence of morbid obesity was 0.6% in 5,824 women. Morbidly obese women were older and were more likely to be multigravidas than women with a normal BMI. The pregnancy was complicated by hypertension in 35.8% and diabetes mellitus in 20.0% of women. Obstetric interventions were high, with an induction rate of 42.1% and a caesarean section rate of 45.3%. Conclusions: Our findings show that maternal morbid obesity is associated with an alarmingly high incidence of medical complications and an increased level of obstetric interventions. Consideration should be given to developing specialised antenatal services for morbidly obese women. The results also highlight the need to evaluate the effectiveness of pre-pregnancy interventions in morbidly obese women.

Checklists to guide critical procedures are becoming an increasingly important part of medical practice. These tools have proved effective in improving outcome in a variety of medical settings, including obstetrics. In this review, we outline essential principles of successful checklist creation and implementation and review our experience with checklist development in a worldwide, multi-institutional health care delivery system.

Although pregnancy-associated stroke is uncommon, the risk of stroke is greatly increased above the low baseline rate in young patients during late pregnancy and, even more so, during the puerperium. Stroke is a major contributor to the serious morbidity and mortality of pregnancy. The physiological hormonally mediated changes in circulation, vascular tissue structure, and coagulability, and the pathological state of pre-eclampsia–eclampsia contribute to this increased risk of stroke. Pregnancy-associated strokes are roughly evenly divided among hemorrhagic strokes, mainly from rupture of aneurysms and arteriovenous malformations (AVMs); ischemic strokes, mainly from late pregnancy and postpartum cerebral venous thrombosis; and strokes associated with pre-eclampsia–eclampsia, with a contribution from cardioembolism, especially in populations at risk from a high rate of underlying rheumatic valvular heart disease. Awareness of the types of stroke to expect during pregnancy will facilitate early diagnosis. This article discusses the pathogenesis of pregnancy-associated stroke, its epidemiology, and some diagnostic and therapeutic issues unique to pregnancy.

Cerebral arteriovenous malformations infrequently complicate pregnancy.We sought to determine the neurologic, obstetric, and ethical significance of such malformations.We present the clinical course of 2 pregnant women with arteriovenous malformations who experienced cerebral hemorrhage and a loss of capacity for decision making.We also review the neurologic and obstetric significance of arteriovenous malformations in pregnancy. Various treatment options with concern for pregnancy and the prognosis for arteriovenous malformations are outlined. The ethical issues involved for pregnant patients whose decisional capacity is compromised as a result of cerebral injury are explored. A review of persistent vegetative state and brain death (death by neurologic criteria) occurring in pregnancy allows us to explore many issues that are applicable to decisionally incapacitated but physiologically functioning pregnant women.We outline a document, the purpose of which is to obtain advance directives from pregnant women regarding end-of-life decisions and to appoint a surrogate decision maker.We believe that evaluation and treatment of the arteriovenous malformation may be undertaken without regard for the pregnancy and that the pregnancy should progress without concern for the arteriovenous malformation.

OBJECTIVES: The purpose of this study was to evaluate the incidence, risk factors, indications, outcomes, and complications of emergency hysterectomy performed after cesarean deliveries (cesarean hysterectomy) and vaginal deliveries (postpartum hysterectomy).
STUDY DESIGN: We conducted a retrospective cohort study from 1990 to 2002 of patients who had peripartum hysterectomies at a single tertiary hospital. Comparisons were made between cesarean and postpartum hysterectomies.
RESULTS: There were 55 cases of emergency peripartum hysterectomy (38 cesarean hysterectomies, and 17 postpartum hysterectomies), for a rate of 0.8 per 1000 deliveries. Overall, the most common indication for hysterectomy was uterine atony (56.4%), followed by placenta accreta (20.0%). Average estimated blood loss was 3325.6+/-1839.2 mL, average operating time was 157.1+/-75.4 minutes, average time from delivery to completing the hysterectomy was 333.8+/-275.7 minutes, and the average length of hospitalization was 11.0+/-7.9 days. The cesarean delivery rate at Grady Memorial Hospital during the study period was 14.2%. There were no statistically significant differences between variables examined when comparisons were made by cesarean vs postpartum hysterectomy.
CONCLUSION: Uterine atony is the leading indication for emergency hysterectomy performed following cesarean and vaginal deliveries.

ABSTRACT: The prevalence of obesity is currently rising in developed countries, making pregravid overweight one of the most common high-risk obstetric situations. Although the designs and populations of published studies vary widely, most authors agree that pregravid overweight increases maternal and fetal morbidity. Even moderate overweight is a risk factor for gestational diabetes and hypertensive disorders of pregnancy,and the risk is higher in subjects with overt obesity. Compared with normal weight, maternal overweight is related to a higher risk of cesarean deliveries and a higher incidence of anesthetic and postoperative complications in these deliveries. Low Apgar scores, macrosomia, and neural tube defects are more frequent in infants of obese mothers than in infants of normal-weight mothers. The regional distribution of fat modulates the effects of weight on carbohydrate tolerance, hemodynamic adaptation, and fetal size. Maternal obesity increases perinatal mortality. Longterm complications include worsening of maternal obesity and development of obesity in the infant. The average cost of hospital prenatal and postnatal care is higher for overweight mothers than for normal-weight mothers, and infants of overweight mothers require admission to neonatal intensive care units more often than do infants of normal-weight mothers. Preconception counseling, careful prenatal management, tight monitoring of weight gain, and long-term follow-up could minimize the social and economic consequences of pregnancies in overweight women.

OBJECTIVE: The purpose of this study was to measure the reliability of a model that defines preventability in maternal morbidity and death.
STUDY DESIGN: One hundred cases of serious morbidity and death among peripartum women were reviewed by 2 independent groups of medical experts to identify potentially preventable provider or system events that may have led to the progression of illness.
RESULTS: Seventy-seven percent of the cases had concordant findings in both groups regarding the identification of any preventable events. Interrater agreement, which was measured by Cohen's Kappa, was 0.49, which suggests moderate to good reliability. Cases with multiple comorbidities, poor documentation, or preventable patient factors tended to have higher levels of disagreement.
CONCLUSION: There was high agreement between the 2 groups regarding the identification of preventable events that impact maternal morbidity and death. The reliability of this model for the assessment of preventability is an important step for improvement in obstetric and medical care.

OBJECTIVE: The objective of this study was to develop a scoring system for identifying women with near-miss maternal morbidity, and differentiating these women from those with severe but not life-threatening conditions.
STUDY DESIGN AND SETTING: The study was conducted at the University of Illinois Medical Center at Chicago (UIMC), which is a tertiary care hospital with approximately 2,220 births per year. UIMC is in a major urban area serving a predominantly African-American and Latina population. This article focuses on five clinical factors: organ failure (>/=1 system), extended intubation (>12 hr), ICU admission, surgical intervention, and transfusion (>3 units), grouped into several scoring system alternatives. The total score on each scoring system was calculated as the weighted sum of the clinical factors present for each woman.
RESULTS: The five-factor scoring system had the highest specificity (93.9%), but the four-factor scoring system, which eliminated organ system failure for simplification of data collection, still had a specificity of 78.1%.
CONCLUSION: Near-miss morbidities identified using the scoring systems presented can be incorporated into clinical case review and epidemiologic studies to enhance the monitoring of obstetric care and to improve estimates of the incidence of life-threatening complications in pregnancy.

Maternal mortality is the major indicator used to monitor maternal health in the United States. For every woman who dies, however, many suffer serious life-threatening complications of pregnancy. Yet relatively little attention has been given to identifying a general category of morbidities that could be called near misses. Characterizing near-miss morbidity is valuable for monitoring the quality of hospital-based obstetric care and for assessing the incidence of life-threatening complications. Cases of near-miss morbidity also provide an appropriate comparison group both for dinical case review and for epidemiologic analysis. This paper presents an initial framework and a process for the definition and identification of near-miss morbidity that minimizes loss of information yet has practical utility. A clinical review team classified 22 of 186 women as near misses and 164 as other severe morbidity. A quantitative score classified 28 women as near misses and 156 as other severe morbidity. Precise classification of near-miss morbidity is the first step in analyzing factors that may differentiate survival from death on the continuum from morbidity to mortality. Ultimately, a methodology for the identification and analysis of near-miss morbidity will allow for integrated morbidity and mortality reviews that can then be institutionalized. The results will serve as important models for other researchers, state health agencies, and regionalized perinatal systems that are engaged in morbidity and mortality surveillance.

Objective: The goal of this study was to examine whether sociodemographic, clinical, and other service-related factors, as well as preventability issues affect a woman’s progression along the continuum of morbidity and mortality. Study design: This was a case-control study of pregnancy-related deaths, women with near-miss morbidity, and those with other severe, but not life threatening, morbidity. Factors associated with maternal outcome were examined. Results: Provider factors (related to preventability) and clinical diagnosis were significantly associated with progression along the continuum after controlling for sociodemographic characteristics (P ! .01 for both associations). Conclusion: In order to improve mortality rates, we must understand maternal morbidity and how it may lead to death. This study shows that important initiatives include addressing preventability, in particular, provider factors, which may play a role in moving women along the continuum of morbidity and mortality.

Objective: The purpose of this study was to evaluate the accuracy of the International Classification of Diseases 9th revision codes for preeclampsia and eclampsia. Study design: The University of Illinois Medical Center at Chicago discharge database was used to identify 135 women from 1999 through 2001 whose disease was coded as having preeclampsia or eclampsia. With American College of Obstetrics and Gynecology criteria as the gold standard, the diagnosis that was determined through chart review was compared with the International Classification of Diseases 9th revision code that was present in the discharge database. Patients were classified as true cases if the International Classification of Diseases 9th revision code matched the American College of Obstetricians and Gynecologists diagnosis; the positive predictive value of the code was then calculated. Results: The overall positive predictive value for the complete sample was only 54%, but the positive predictive value for severe preeclampsia was 84.8%, which was high compared with mild preeclampsia (45.3%) and eclampsia (41.7%). Diagnostic (clinician) error was the most common reason for miscoding error. Conclusion: The findings suggest that International Classification of Diseases 9th revision codes for preeclampsia/eclampsia vary greatly in their accuracy of diagnosis. Therefore, a review of medical records is required when data are being gathered on the incidence of preeclampsia and eclampsia.

Objectives: The purpose of this study was to assess whether African-American women are at increased risk of having peripartum cardiomyopathy. Background: Peripartum cardiomyopathy is a heart disease of unknown cause that affects young women, often with devastating consequences. The frequency of peripartum cardiomyopathy varies markedly between African and non-African regions. Methods: A case-control study was performed at a regional center that provides medical care to a racially heterogeneous population. For each case, 3 healthy control patients were randomly selected who delivered babies within the same month. Results: African-American women had a 15.7-fold higher relative risk of peripartum cardiomyopathy than non–African Americans (odds ratio [OR]: 15.7, 95% confidence interval [CI]: 3.5 to 70.6). Other significant univariate risk factors were hypertension (
OR: 10.8, 95%
CI: 2.6 to 44.4), being unmarried (
OR: 4.2, 95%
CI: 1.4 to 12.3), and having had >2 previous pregnancies (
OR: 2.9, 95%
CI: 1.1 to 7.4). African-American ethnicity remained a significant risk factor for peripartum cardiomyopathy when other risk factors were considered in multivariable (
OR: 31.5, 95%
CI: 3.6 to 277.6) and stratified analyses (
OR: 12.9 to 29.1, p <0.001). Although the frequency of peripartum cardiomyopathy (185 of 100,000 deliveries) at this center was higher than in previous U.S. reports, it was comparable to the frequency in countries with more women of African descent (100 to 980 of 100,000). Analysis of other U.S. studies confirmed that the frequency of peripartum cardiomyopathy was significantly higher among African-American women.

Preeclampsia, characterized by new-onset gestational hypertension and proteinuria, is a common and serious complication of pregnancy. Evidence from both animal and human studies has implicated placental ischemia and hypoxia as a central causative factor in the etiology of the disorder. The ischemic placenta in turn initiates a cascade of secondary effector mechanisms, including altered proangiogenic and antiangiogenic factor balance, increase in maternal oxidative stress and endothelial and immunological dysfunction. The full elucidation of these mechanisms will hopefully lead to a more complete understanding of the etiology of preeclampsia and lead to

OBJECTIVE: To estimate the rate of peripartum hysterectomy over the last 8 years in Calgary, the primary indication for peripartum hysterectomy (defined as any hysterectomy performed within 24 hours of a delivery), and whether there was an increase in the rate of peripartum hysterectomy during that time.
METHOD: Detailed chart review of all cases of peripartum hysterectomy, 1999-2006, including previous obstetric history, details of the index pregnancy, indications for peripartum hysterectomy, outcome of the hysterectomy, and infant morbidity.
RESULTS: The overall rate of peripartum hysterectomy was 87 of 108,154 or 0.8 per 1,000 deliveries. The primary indications for hysterectomy were uterine atony (32 of 87, 37%) and suspected placenta accreta (29 of 87, 33%). After hysterectomy, 46 (53%) women were admitted to the intensive care unit. Women were discharged home after a mean 6-day length of stay. The rate of peripartum hysterectomy did not appear to increase over time.
CONCLUSION: Our population-based study found that abnormal placentation is the main indication for peripartum hysterectomy. The most important step in prevention of major postpartum hemorrhage is recognizing and assessing women's risk, although even perfect management of hemorrhage cannot always prevent surgery.
LEVEL OF EVIDENCE: III.

OBJECTIVE: To identify risk factors for life-threatening maternal outcomes.
STUDY DESIGN: Hospital charts were reviewed for cases of maternal mortality or near-miss and for controls overmatched 1:3. Significant risk factors were identified through simple and best subsets multiple logistic regression.
RESULT: Eight cases of mortality and 69 near-miss cases were found. Significant risk factors with their odds ratios and 95% confidence intervals are: age 35 to 39 years (2.3, 1.2 to 4.4) and >39 years (5.1, 1.8 to 14.4); African-American race (7.4, 2.5 to 22.0) and Hispanic ethnicity (4.2, 1.3 to 13.2); chronic medical condition (2.7, 1.5 to 4.8); obesity (3.0, 1.7 to 5.3); prior cesarean (5.2, 2.8 to 9.8) and gravidity (1.2, 1.1 to 1.5 per pregnancy). In multivariable logistic regression, race remained significant while controlling for other significant factors and markers of socioeconomic status.
CONCLUSION: Some risk factors can be modified through medical care, education or social support systems. Racial disparity in outcome is confirmed and is unexplained by traditional risk factors.

SMFM Poster OBJECTIVE: Describe pregnancy associated deep vein thrombosis (DVT) and pulmonary embolism (PE) by method of delivery, and evaluate its potential use as an indicator of healthcare quality. STUDY DESIGN: Using 2003 California discharge data, rates of DVT/PE were calculated for antepartum, delivery, and postpartum discharges at the hospital level. Criteria suggested by Agency for Healthcare Research and Quality was used to evaluate the potential for DVT/PE to be used as a measure of hospital quality-- importance, scientific acceptability, usability, and feasibility. RESULTS: There were 48,015 antepartum admissions, 525,354 delivery discharges, and 17,981 postpartum admissions. Amongst antepartum admissions, there were 139 (0.29%) DVT and 39 (0.12%) cases of PE. There were total of 222 (0.04%) women with delivery associated DVT (180) or PE (42). Women undergoing cesarean delivery were more likely to have DVT/PE as compared to women delivering vaginally (0.09% vs 0.03%)*. Postpartum admissions included 98 (0.55%) and 58 (0.32%) cases ofDVTand PE respectively, and were more common among patients with cesarean delivery (0.08% vs. 0.03%)*. The mean rate of DVT/PE for delivery or postpartum admissions by hospital was 0.08% (0% to 1.1%) with 45.5% of hospitals reporting no events. *p
0.0001 CONCLUSION: Women undergoing cesarean delivery are more likely to experience DVT/PE. DVT/PE is not a good quality indicator measure. Although clinically important (significant cause of maternal morbidity and mortality), and scientifically acceptable (prophylaxis could impact incidence), the prevalence is low. It is not usable as a measure of hospital quality of care as rates of DVT/PE do not vary significantly by hospital. It is feasible to monitor based on aggregate data reporting, but further validation is needed to determine the reliability of reporting.

Preeclampsia is a leading cause of maternal and fetal/neonatal mortality and morbidity worldwide. The early identification of patients with an increased risk for preeclampsia is therefore one of the most important goals in obstetrics. The availability of highly sensitive and specific physiologic and biochemical markers would allow not only the detection of patients at risk but also permit a close surveillance, an exact diagnosis, timely intervention (e.g. lung maturation), as well as simplified recruitment for future studies looking at therapeutic medications and additional prospective markers. Today, several markers may offer the potential to be used, most likely in a combinatory analysis, as predictors or diagnostic tools. We present here the current knowledge on the biology of preeclampsia and review several biochemical markers which may be used to monitor preeclampsia in a future, that, we hope, is not to distant from today. This article is available from: http://www.rbej.com/content/7/1/70

Objectives: To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework for deciding when it is efficient to develop and introduce clinical guidelines. Data sources: MEDLINE, Healthstar, Cochrane Controlled Trial Register, EMBASE, SIGLE and the specialised register of the Cochrane Effective Practice and Organisation of Care (EPOC) group. Review methods: Single estimates of dichotomous process variables were derived for each study comparison based upon the primary end-point or the median measure across several reported end-points. Separate analyses were undertaken for comparisons of different types of intervention. The study also explored whether the effects of multifaceted interventions increased with the number of intervention components. Studies reporting economic data were also critically appraised. A survey to estimate the feasibility and likely resource requirements of guideline dissemination and implementation strategies in UK settings was carried out with key informants from primary and secondary care. Results: In total, 235 studies reporting 309 comparisons met the inclusion criteria; of these 73% of comparisons evaluated multifaceted interventions, although the maximum number of replications of a specific multifaceted intervention was 11 comparisons. Overall, the majority of comparisons reporting dichotomous process data observed improvements in care; however, there was considerable variation in the observed effects both within and across interventions. Commonly evaluated single interventions were reminders, dissemination of educational materials, and audit and feedback. There were 23 comparisons of multifaceted interventions involving educational outreach. The majority of interventions observed modest to moderate improvements in care. No relationship was found between the number of component interventions and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. The majority of studies only reported costs of treatment; only 25 studies reported data on the costs of guideline development or guideline dissemination and implementation. The majority of studies used process measures for their primary end-point, despite the fact that only three guidelines were explicitly evidence based (and may not have been efficient). Respondents to the key informant survey rarely identified existing budgets to support guideline dissemination and implementation strategies. In general, the respondents thought that only dissemination of educational materials and short (lunchtime) educational meetings were generally feasible within current resources. Conclusions: There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgement about how best to use the limited resources they have for clinical governance and related activities to maximise population benefits. They need to consider the potential clinical areas for clinical effectiveness activities, the likely benefits and costs required to introduce guidelines and the likely benefits and costs as a result of any changes in provider behaviour. Further research is required to: develop and validate a coherent theoretical framework of health professional and organisational behaviour and behaviour change to inform better the choice of interventions in research and service settings, and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.

OBJECTIVES: To estimate the incidence, describe the mortality, and identify independent predictors of peripartum cardiomyopathy, a very serious cardiovascular complication of pregnancy associated with maternal morbidity and mortality among otherwise healthy women without prior heart disease. METHODS: We identified all cases of diagnosed heart failure that occurred among women within 1 month before to 5 months after delivery of a liveborn neonate in Kaiser Permanente Northern California delivery hospitals between 1995 and 2004. Incident peripartum cardiomyopathy was confirmed from medical records documenting dilated cardiomyopathy with reduced left ventricular systolic function after excluding women with prior heart failure or valvular disease. Data sources included medical records, electronic clinical databases, and state birth and death files. RESULTS: Among 227,224 eligible women, we confirmed 110 recognized peripartum cardiomyopathy cases (incidence: 4.84 per 10,000 live births, 95% confidence interval 3.98 –5.83). Independent predictors included maternal age of 25 years or older, non-Hispanic African American and Filipino groups, parity of 4 or greater, multiple gestation, severe anemia, pre-existing and pregnancyrelated hypertensive disorders, and hemolysis, elevated liver enzymes, low platelets syndrome. Maternal death rate (per 1,000 person-years) was higher among cases (6.12) than noncases (0.23; P<.001). Neonates whose mothers developed peripartum cardiomyopathy experienced poorer clinical outcomes. CONCLUSION: Within a large, diverse northern California population, 1 of every 2,066 women delivering a liveborn neonate had recognized, confirmed peripartum cardiomyopathy, which was associated with higher maternal and neonatal death rates and worse neonatal outcomes. Several readily available patient characteristics can be used to identify women at risk for this severe pregnancy complication.

Objective: This study was undertaken to determine maternal and perinatal outcomes after expectant management of severe preeclampsia between 24 and 33 weeks’ gestation. Study design: A prospective observational study of 239 women with severe preeclamptic and undelivered after antenatal steroid prophylaxis was performed. Pregnancy prolongation and maternal and perinatal morbidities were analyzed according to the gestational age at time of expectant management: 24 to 28, 29 to 31, and 32 to 33 weeks. Statistical analysis was performed by Student t test and c2 test. Results: The days of pregnancy prolongation were significantly higher among those managed at less than 29 weeks (6) compared with the other groups (4). There were 13 perinatal deaths: 12 in those managed at less than 29 weeks and 1 in those managed at 29 to 31 weeks. Neonatal morbidities were significantly higher among those managed at less than 29 weeks compared with the other groups. There were no instances of maternal death or eclampsia. Maternal morbidities were similar among the groups. Conclusion: Expectant management of severe preeclampsia at 24 to 33 weeks in a tertiary care center is associated with good perinatal outcome with a minimal risk for the mother.

Objective: To explore the association between striae gravidarum (SG) and the risk for perineal trauma (PT) in childbirth. Design: A cross-sectional study. Setting: Maternity ward in 5 university medical centers. Participants: Three hundred and eighty-five women (28.9  5.3 years old) who delivered vaginally. Methods: Striae gravidarum score was assessed using the Atwal numerical scoring system. The association was examined between PT as the outcome measure, defined by tears or laceration, and the total striae scores (TSS) obtained at the abdomen, hips, buttocks, and breast. Results: Significantly higher TSS scores were found in women with PT compared with women without PT (3.60  0.39 vs. 2.31  0.23, p5.003). Specifically, striae scores at the breast and hips were significantly higher among women who had PT. Logistic regression analysis revealed that TSS (OR50.079; 95% CI 1.012, 1.151; p5.021), as well as a rise in body mass index (BMI) during pregnancy (OR51.025; 95% CI 1.001, 1.049; p5.043) are significant predictors of PT. Conclusions: This study demonstrates a significant relation between SG and PT. The findings suggest that SG assessment may be used in the clinical setting by midwives and nurses as a simple and noninvasive tool to better define women at risk for PT.

Objective: To determine maternal and perinatal outcomes in nulliparas with pregnancy-associated hypertension or preeclampsia. Methods: We conducted (and reported elsewhere) a randomized, double-masked, placebo-controlled trial calcium supplementation of 4589 healthy nulliparas assigned at 13–21 weeks’ gestation. This well-defined and characterized data set provided an opportunity to detail more precisely adverse maternal, fetal, and newborn outcomes in women who developed hypertension among a prospective series of healthy nulliparas. Results: Of 4302 women observed to or beyond 20 weeks’ gestation, 1073 (24.9%) developed mild or severe pregnancyassociated hypertension or preeclampsia. One hundred sixteen women of the 1073 with hypertension (10.8%) and 336 of the 3229 without hypertension (10.4%) were delivered before 37 weeks’ gestation. Fetal and neonatal mortality were similar in those groups; however, selected maternal and newborn morbidities were significantly greater in women with hypertension. Significantly increased maternal morbidities included increased cesarean deliveries, abruptio placentae, and acute renal dysfunction; and significantly increased perinatal morbidities included respiratory distress syndrome, ventilatory support, and fetal growth restriction. Adverse outcomes were highest in women with severe pregnancy-associated hypertension or preeclampsia. Conclusion: Hypertension, especially severe hypertension, was associated with an appreciable increase in important maternal and perinatal morbidity but not perinatal mortality.

OBJECTIVES: To identify pregnant and postpartum patients admitted to intensive care units (ICUs), the cause for their admission, and the proportion that might be appropriately managed in a high-dependency environment (HDU) by using an existing database. To estimate the goodness-of-fit for the Simplified Acute Physiology Score II, the Acute Physiology and Chronic Health Evaluation (APACHE) II, and the APACHE III scoring systems in the obstetrical population.
DESIGN: Retrospective analysis of demographic, diagnostic, treatment, and severity of illness data.
SETTING: Fourteen ICUs in Southern England.
PATIENTS: Pregnant or postpartum (<42 days) admissions between January 1, 1994, and December 31, 1996.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: We identified 210 patients, constituting 1.84% (210 of 11,385) of all ICU admissions and 0.17% (210 of 122,850) of all deliveries. Most admissions followed postpartum complications (hypertensive disease of pregnancy [39.5%] and major hemorrhage [33.3%]). Seven women were transferred to specialist ICUs. There was considerable variation between ICUs with respect to the number and type of interventions required by patients. Some 35.7% of patients stayed in ICU for <2 days and received no specific ICU interventions; these patients might have been safely managed in an HDU. There were seven maternal deaths (3.3%); fetal mortality rate was 20%. The area under the receiver operator characteristic curve and the standardized mortality ratio were 0.92 (confidence interval [CI], 0.85-0.99) and 0.43 for the Simplified Acute Physiology Score II, 0.94 (CI, 0.86-1.0) and 0.24 for APACHE II, and 0.98 (CI, 0.96-1.0) and 0.43 for APACHE III, respectively.
CONCLUSIONS: Existing databases can both identify critically ill obstetrical patients and provide important information about them. Obstetrical ICU admissions often require minimal intervention and are associated with low mortality rates. Many might be more appropriately managed in an HDU. The commonly used severity of illness scoring systems are good discriminators of outcome from intensive care admission in this group but may overestimate mortality rates. Severity of illness scoring systems may require modification in obstetrical patients to adjust for the normal physiologic responses to pregnancy.

OBJECTIVE: To determine the frequency of and risk factors for serious morbidity resulting in a prolonged hospital stay or readmission among women enrolled in Tennessee's Medicaid program who delivered live or dead infants in 1991.
METHODS: This retrospective cohort study included 33,251 women of white or black ethnicity. Main outcome measures included childbirth-related medical conditions serious enough to result in death, prolonged delivery hospitalization, or readmission within 60 days of delivery.
RESULTS: Among 25,810 women with vaginal (78%) and 7441 (22%) women with cesarean deliveries, 2.6% and 8.9%, respectively, had at least one childbirth-related medical condition requiring prolonged delivery hospitalization or readmission, including infection (1.8% and 7.9%), hypertension-related complications (0.7% and 2.0%), or hemorrhage (0.5% and 2.4%). After controlling for other risk factors, maternal age over 32 years was independently associated with increased rate of serious morbidity among women who had vaginal (relative risk [RR] 1.9, 95% confidence interval [CI] 1.4, 2.7) or cesarean deliveries (RR 1.6, 95% CI 1.1, 2.2). Black women had approximately twice the rate of maternal morbidity with vaginal (RR 1.9, 95% CI 1.5, 2.4) or cesarean deliveries (RR 2.3, 95% CI 1.9, 2.9). Primiparous women who had vaginal or cesarean deliveries had a 60% (RR 1.6, 95% CI 1.3, 2.0) and 70% (RR 1.7, 95% CI 1.4, 2.0), respectively, greater risk of serious maternal morbidity than women with 1-3 prior births.
CONCLUSION: Predictors of serious maternal morbidity included age over 32 years, black ethnicity, and primiparity.

Preeclampsia is a leading cause of perinatal morbidity and mortality. This disorder is thought to be multifactorial in origin, with multiple genes, environmental and social factors, contributing to disease. One proposed mechanism is placental hypoxia-driven imbalances in angiogenic and anti-angiogenic factors, causing endothelial cell dysfunction. Catechol-Omethyltransferase (Comt)-deficient pregnant mice have a preeclampsia phenotype that is reversed by exogenous 2-methoxyestradiol (2-ME), an estrogen metabolite generated by COMT. 2-ME inhibits Hypoxia Inducible Factor 1a, a transcription factor mediating hypoxic responses. COMT has been shown to interact with methylenetetrahydrofolate reductase (MTHFR), which modulates the availability of S-adenosylmethionine (SAM), a COMT cofactor. Variations in MTHFR have been associated with preeclampsia. By accounting for allelic variation in both genes, the role of COMT has been clarified. COMT allelic variation is linked to enzyme activity and four single nucleotide polymorphisms (SNPs) (rs6269, rs4633, rs4680, and rs4818) form haplotypes that characterize COMT activity. We tested for association between COMT haplotypes and the MTHFR 677 CRT polymorphism and preeclampsia risk in 1103 Chilean maternal-fetal dyads. The maternal ACCG COMT haplotype was associated with reduced risk for preeclampsia (P = 0.004), and that risk increased linearly from low to high activity haplotypes (P = 0.003). In fetal samples, we found that the fetal ATCA COMT haplotype and the fetal MTHFR minor ‘‘T’’ allele interact to increase preeclampsia risk (p = 0.022). We found a higher than expected number of patients with preeclampsia with both the fetal risk alleles alone (P = 0.052) and the fetal risk alleles in combination with a maternal balancing allele (P,0.001). This non-random distribution was not observed in controls (P = 0.341 and P = 0.219, respectively). Our findings demonstrate a role for both maternal and fetal COMT in preeclampsia and highlight the importance of including allelic variation in MTHFR.

ABSTRACT: Background: Preeclampsia is a major complication of pregnancy associated with increased maternal morbidity and mortality, and adverse birth outcomes. The objective of this study was to describe changes in all domains of health-related quality of life between 6 and 12 weeks postpartum after mild and severe preeclampsia; to assess the extent to which it differs after mild and severe preeclampsia; and to assess which factors contribute to such differences. Methods: We conducted a prospective multicenter cohort study of 174 postpartum women who experienced preeclampsia, and who gave birth between February 2007 and June 2009. Health-related quality of life was measured at 6 and 12 weeks postpartum by the RAND 36-item Short-Form Health Survey (SF-36). The population for analysis comprised women (74%) who obtained scores on the questionnaire at both time points. Results: Women who experienced severe preeclampsia had a lower postpartum health-related quality of life than those who had mild preeclampsia (all p < 0.05 at 6 wk postpartum). Quality of life improved on almost all SF-36 scales from 6 to 12 weeks postpartum (p < 0.05). Compared with women who had mild preeclampsia, those who experienced severe preeclampsia had a poorer mental quality of life at 12 weeks postpartum (p < 0.05). Neonatal intensive care unit admission and perinatal death were contributing factors to this poorer mental quality of life. Conclusions: Obstetric caregivers should be aware of poor health-related quality of life, particularly mental health quality of life in women who have experienced severe preeclampsia (especially those confronted with perinatal death or their child’s admission to a neonatal intensive care unit), and should consider referral for postpartum psychological care. (BIRTH 38:3 September 2011)

Some thrombophilias and severe preeclampsia may increase the risk for preterm deliveries and fetal death due to placental insufficiency. Our objective was to evaluate clinical and laboratory data as predictors of preeclampsia in a population of mothers with 3rd trimester fetal losses or preterm deliveries. In a longitudinal retrospective study, 54 consecutive women (age range: 16 to 39 years) with normotensive pregnancies were compared to 79 consecutive women with preeclampsia (age range: 16 to 43 years). Weight accrual rate (WAR) was arbitrarily defined as weight gain from age 18 years to the beginning of pregnancy divided by elapsed years. Independent predictors of preeclampsia were past history of oligomenorrhea, WAR >0.8 kg/years, pre-pregnancy or 1st trimester triglyceridemia >150 mg/dL, and elevated acanthosis nigricans in the neck. In a multivariate logistic regression model, two or more predictors conferred an odds ratio of 15 (95%CI [5.9‑37]; P < 0.001) to develop preeclampsia (85% specificity, 73% sensitivity, c-statistic of 81 ± 4%; P < 0.0001). Clinical markers related to insulin resistance and sedentary lifestyles are strong independent predictors of preeclampsia in mothers with 3rd trimester fetal losses or preterm deliveries due to placental insufficiency. Women at risk for preeclampsia in this particular population might benefit from measures focused on overcoming insulin resistance.

ABSTRACT: Context: Pregnant women in rural areas may give birth in either rural or urban hospitals. Differences in outcomes between rural and urban hospitals may influence patient decision making. Purpose: Trends in rural and urban obstetric deliveries and neonatal and maternal mortality in California were compared to inform policy development and patient and provider decision making in rural health care settings. Methods: Deliveries in California hospitals identified by the California Department of Health Services, Birth Statistical Master Files for years 1998 through 2002 were analyzed. Three groups of interest were created: rural hospital births to all mothers, urban hospital births to rural mothers, and urban hospital births to urban mothers. Findings: Of 2,620,096 births analyzed, less than 4% were at rural hospitals. Neonatal death rates were significantly higher in babies born to rural mothers with no pregnancy complications who delivered a normal weight baby vaginally at an urban hospital compared to urban mothers delivering at an urban hospital (0.2 [CI 0.2-0.4] deaths per 1,000 births versus 0.1 [CI 0.1-0.1]). Logistic regression analysis showed that delivery in a rural hospital was a protective factor compared to urban mothers delivering in an urban hospital, with an odds ratio of 0.8 (CI 0.6-0.9). Maternal death rates were not different. Conclusions: Rural obstetric services in this period showed favorable neonatal and maternal safety profiles. This information should reassure patients considering a rural hospital delivery, and aid policy makers and health care providers striving to ensure access to obstetric services for rural populations.

Objective: To examine associations of gravidity and parity with all-cause, cardiovascular disease (CVD), and coronary heart disease (CHD) mortality in postmenopausal women. Design: Prospective cohort study. Setting: Rancho Bernardo, a southern California community. Patient(s): One thousand two hundred ninety-four postmenopausal women ages 50–96 who attended a 1984–87 research clinic visit at which reproductive and medical histories were obtained and who were followed through 2007. Intervention(s): None. Main Outcome Measure(s): All-cause, CVD, CHD, and non-CHD CVD mortality, determined by nosologist-coded death certificates. Result(s): Average baseline age was 70.6
9.2. Numbers of pregnancies ranged from 0 to 13 (median ¼ 2); births ranged from 0 to 11 (median ¼ 2). During a median of 19.3 years of follow-up, 707 women (54.6%) died, with 46.5% attributed to CVD, 20.5% to CHD, and 26.0% to non-CHD CVD. Trend analyses showed inverse associations of gravidity with CVD mortality and non-CHD CVD mortality. Women with four or more pregnancies were less likely than nulligravidas to have fatal CVD (hazard ratio [HR] ¼ 0.63, 95% confidence interval [CI] ¼ 0.40–0.99) and non-CHD CVD (HR ¼ 0.48, 95% CI ¼ 0.26–0.91) independent of age, years postmenopause, obesity, and HDL. Associations increased after the first decade of follow-up. Parity and gravidity were not associated with overall or CHD mortality. Conclusion(s): High gravidity was associated with reduced CVD and non-CHD CVD mortality in postmenopausal women. Protective associations could reflect biological mechanisms that occur with repeated pregnancy or greater social support related to family size among multiparous women.

OBJECTIVE: The purpose of this study was to describe the characteristics and outcomes of obstetric patients who require mechanical ventilation. STUDY DESIGN: A review was conducted of obstetric patients who required mechanical ventilation and who received care at our institutions between 1990 and 1998. Data that were collected included maternal demographics, medical condition that necessitated ventilation, delivery status, duration of ventilation, onset of parturition while receiving ventilation, mode of delivery, and maternal and early neonatal morbidity or death. RESULTS: Fifty-one women were identified; 43 women(84%) received care in the labor and delivery setting. The most common admission diagnoses were preeclampsia/eclampsia (44%), labor/preterm labor (14%), and pneumonia (12%). Forty-three women (86%) were undelivered on admission (mean gestational age, 31.6 weeks). Delivery occurred in 37 women (86%) during their admission; 24 women (65%) underwent cesarean delivery. Eleven women began labor while receiving ventilation; 6 were delivered vaginally. The maternal mortality rate was 14% (7/51 women), and the perinatal mortality rate was 11% (4/37 fetuses). CONCLUSION: A large number of obstetric patients who receive mechanical ventilation will require delivery because of their condition. Centers that care for such women should form a treatment strategy to coordinate obstetric and medical care for this unique population

The prevalence of obesity is growing among reproductive-age women. This is concerning because obesity has significant health-related consequences. Aside from the long-term risks of diabetes, heart disease, and some types of cancer, obesity poses immediate threats for young women including subfertility and adverse early and late pregnancy outcomes. Epidemiologic and experimental studies demonstrate associations between prepregnancy obesity and poor reproductive outcomes; however, the mechanisms involved are poorly understood. We discuss current knowledge of the pathophysiology of obesity in early reproductive events and how these events may affect reproductive outcomes including fertility and miscarriage risk. We also discuss avenues for future research and interventions to improve reproductive outcomes for obese women.

Obstetric patients are a small but important group of patients in the intensive care unit (ICU). Their problems are unique and need specialized attention. Decision making may be confounded by physiologic changes in pregnancy. In developed countries with good antenatal care, comparatively fewer obstetric patients are admitted to ICUs, but the maternal mortality rate remains high in the developing countries. Medical disorders and organ dysfunction caused by critical illness of pregnancy differ from region to region. With improvement in antenatal care, the number of ICU admissions for obstetric disorders would decline in developing countries; however, this number may increase gradually in developed countries because of increasing maternal age and pregnancies in women with complicated chronic medical disorders.

OBJECTIVE: The purpose of this study was to determine the effectiveness of postpartum dexamethasone in patients with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. STUDY DESIGN: A prospective, randomized, double-blind trial was conducted in which 105 women with HELLP syndrome were enrolled and assigned randomly to treatment or placebo groups following delivery. Duration of hospital stay, maternal morbidity, and laboratory and clinical parameters were evaluated. RESULTS: There was no difference in maternal morbidity or mortality between the 2 groups. There was also no difference in duration of hospitalization and the need for rescue scheme or the use of blood products between groups. Linear model adjustments showed no significant difference between groups with respect to the pattern of platelet count recovery, aspartate aminotransferase, lactate dehydrogenase, hemoglobin,or diuresis. CONCLUSION: These findings do not support the use of dexamethasone in the puerperium for recovery of patients with HELLP syndrome.

OBJECTIVE: To examine the effect of gestational weight change on pregnancy outcomes in obese women. METHODS: A population-based cohort study of 120,251 pregnant, obese women delivering full-term, liveborn, singleton infants was examined to assess the risk of four pregnancy outcomes (preeclampsia, cesarean delivery, small for gestational age births, and large for gestational age births) by obesity class and total gestational weight gain. RESULTS: Gestational weight gain incidence for overweight or obese pregnant women, less than the currently recommended 15 lb, was associated with a significantly lower risk of preeclampsia, cesarean delivery, and large for gestational age birth and higher risk of small for gestational age birth. These results were similar for each National Institutes of Health obesity class (30 –34.9, 35–35.9, and 40.0 kg/m2), but at different amounts of gestational weight gain. CONCLUSION: Limited or no weight gain in obese pregnant women has favorable pregnancy outcomes

OBJECTIVE: Pre-pregnancy obesity poses risks to both pregnant women and their infants. This study used a large population-based data source to examine trends, from 1993 through 2003, in the prevalence of pre-pregnancy obesity among women who delivered live infants. METHODS: Data from the Pregnancy Risk Assessment Monitoring System in nine states were analyzed for trends in pre-pregnancy obesity (BMI
29.0 kg/m2) overall and by maternal demographic and behavioral characteristics. Pre-pregnancy BMI was calculated from self-reported weight and height on questionnaires administered after delivery, and demographic characteristics were taken from linked birth certificates. The sample of 66,221 births was weighted to adjust for survey design, non-coverage, and non-response, and it is representative of all women delivering a live birth in each particular state. The sampled births represented 18.5% of all births in the United States. RESULTS: Pre-pregnancy obesity increased 69.3% during the study period, from 13.0% in 1993 to 1994 to 22.0% in 2002 to 2003. The percentage increase ranged from 45% to 105% for individual states. Subgroups of women with the highest prevalence of obesity in 2002 to 2003 were those who were 20 to 29 years of age, black, had three or more children, had a high school education, enrolled in Women, Infants, and Children, or were non-smokers. However, all subgroups of women examined experienced at least a 43% increase in pre-pregnancy obesity over this time period. DISCUSSION: The prevalence of pre-pregnancy obesity is increasing among women in these nine states, and this trend has important implications for all stages of reproductive health care.

About one third of all pregnant women in the United States are obese. Maternal obesity at conception alters gestational metabolic adjustments and affects placental, embryonic, and fetal growth and development. Neural tube defects and other developmental anomalies are more common in infants born to obese women; these defects have been linked to poor glycemic control. Preeclampsia, a gestational disorder occurring more frequently in obese women, appears to be due to a subclinical inflammatory state that impairs early placentation and development of its blood supply. Fetal growth and development during the last half of pregnancy depends on maternal metabolic adjustments dictated by placental hormones and the subsequent oxygen and nutrient supply. Maternal obesity affects these metabolic adjustments as well. Basal metabolic rates are significantly higher in obese women, and maternal fat gain is lower, possibly in response to altered leptin function. The usual increase in insulin resistance seen in late pregnancy is enhanced in obese mothers, causing marked postprandial increases in glucose, lipids, and amino acids and excessive fetal exposure to fuel sources, which in turn increases fetal size, fat stores, and risk for disease postnatally. Impaired glucose tolerance, gestational diabetes, and hyperlipidemia are more common among obese mothers. To date, little attention has been given to the role of diet among obese women in preventing these problems. However, studies of women with impaired glucose tolerance show that replacing refined carbohydrates and saturated fat with complex, low-glycemic carbohydrates and polyunsaturated fatty acids improves metabolic homeostasis and pregnancy outcomes. Thus, current dietary guidelines regarding the amount and type of carbohydrates and fat for nonpregnant women seem appropriate for pregnant women as well.

Background It is widely believed that pregnancy increases the risk of stroke, but there are few data available to quantify that risk. Methods We identified all female patients 15 through 44 years of age in central Maryland and Washington, D.C., who were discharged from any of 46 hospitals in the study area in 1988 or 1991. Two neurologists reviewed each case, using data from the women’s medical records. We determined whether the women had been pregnant at the time of the stroke or up to six weeks before it occurred. For purposes of this analysis, the six-week period after pregnancy could begin with an induced or spontaneous abortion or with the delivery of a live or stillborn child. Results Seventeen cerebral infarctions and 14 intracerebral hemorrhages occurred in women who were or had recently been pregnant (pregnancy-related strokes), and there were 175 cerebral infarctions and 48 intracerebral hemorrhages that were not related to pregnancy. For cerebral infarction, the relative risk during pregnancy, adjusted for age and race, was 0.7 (95 percent confidence interval, 0.3 to 1.6), but it increased to 8.7 for the postpartum period (after a live birth or stillbirth) (95 percent confidence interval, 4.6 to 16.7). For intracerebral hemorrhage, the adjusted relative risk was 2.5 during pregnancy (95 percent confidence interval, 1.0 to 6.4) but 28.3 for the postpartum period (95 percent confidence interval, 13.0 to 61.4). Overall, for either type of stroke during or within six weeks after pregnancy, the adjusted relative risk was 2.4 (95 percent confidence interval, 1.6 to 3.6), and the attributable, or excess, risk was 8.1 strokes per 100,000 pregnancies (95 percent confidence interval, 6.4 to 9.7). Conclusions The risks of both cerebral infarction and intracerebral hemorrhage are increased in the six weeks after delivery but not during pregnancy itself.

Objective: To describe on a national basis ethnic differences in severe maternal morbidity in the United Kingdom. Design: National cohort study using the UK Obstetric Surveillance System (UKOSS). Setting: All hospitals with consultant led maternity units in the UK. Participants: 686 women with severe maternal morbidity between February 2005 and February 2006. Main outcome measures: Rates, risk ratios, and odds ratios of severe maternal morbidity in different ethnic groups. Results: 686 cases of severe maternal morbidity were reported in an estimated 775 186 maternities, representing an estimated incidence of 89 (95% confidence interval 82 to 95) cases per 100 000 maternities. 74% of women were white, and 26% were non-white. The estimated risk of severe maternal morbidity in white women was 80 cases per 100 000 maternities, and that in non-white women was 126 cases per 100 000 (risk difference 46 (27 to 66) cases per 100 000; risk ratio 1.58, 95% confidence interval 1.33 to 1.87). Black African women (risk difference 108 (18 to 197) cases per 100 000 maternities; risk ratio 2.35, 1.45 to 3.81) and black Caribbean women (risk difference 116 (59 to 172) cases per 100 000 maternities; risk ratio 2.45, 1.81 to 3.31) had the highest risk compared with white women. The risk in non-white women remained high after adjustment for differences in age, socioeconomic and smoking status, body mass index, and parity (odds ratio 1.50, 1.15 to 1.96). Conclusions: Severe maternal morbidity is significantly more common among non-white women than among white women in the UK, particularly in black African and Caribbean ethnic groups. This pattern is very similar to reported ethnic differences in maternal death rates. These differences may be due to the presence of pre-existing maternal medical factors or to factors related to care during pregnancy, labour, and birth; they are unlikely to be due to differences in age, socioeconomic or smoking status, body mass index, or parity. This highlights to clinicians and policy makers the importance of tailored maternity services and improved access to care for women from ethnic minorities. National information on the ethnicity of women giving birth in the UK is needed to enable ongoing accurate study of these inequalities.

Objectives: To identify women undergoing peripartum hysterectomy in the UK and to describe the causes, management and outcome of the associated haemorrhage. Design: A population-based descriptive study using the UK Obstetric Surveillance System (UKOSS). Setting: All 229 hospitals with consultant-led maternity units in the UK. Population: All women in the UK delivering between February 2005 and February 2006. Methods: Prospective case identification through the UKOSS monthly mailing. Main outcome measures: Rates with 95% CIs. Odds ratio estimates. Results: Three hundred and eighteen women underwent peripartum hysterectomy. The most commonly reported causes of haemorrhage were uterine atony (53%) and morbidly adherent placenta (39%). Women were not universally managed with uterotonic therapies. Fifty women were unsuccessfully managed with B-Lynch or other brace suture prior to hysterectomy, 28 with activated factor VII and 9 with arterial embolisation. Twenty-one percent of women suffered damage to other structures, 20% required a further operation and 19% were reported to have additional severe morbidity. Bladder damage was more likely in women with placenta accreta (OR 3.41, 95% CI 1.55–7.48) than in women with uterine atony. There were no significant differences in outcomes between women undergoing total or subtotal hysterectomy. Two women died; case fatality 0.6% (95% CI 0–1.5%). Conclusions: For each woman who dies in the UK following peripartum hysterectomy, more than 150 survive. The associated haemorrhage is managed in a variety of ways and not universally according to existing guidelines. Further investigation of the outcomes following some of the more innovative therapies for control of haemorrhage is needed.

Objective: To evaluate patient knowledge of the risks of maternal obesity and compare knowledge between non-obese and obese women. Study Design: A face-to-face survey was administered to 105 women at their first prenatal visit. The survey assessed their knowledge of obesityrelated risks during pregnancy, weight history and goals and health behaviors. Descriptive statistics described the entire sample. Student’s t-test and w2 tests compared knowledge between non-obese (body mass index (BMI) of <30 kgm–2) and obese (BMI of X30 kg m–2) gravidas. Result: There were 56 (54%) non-obese and 47 (46%) obese participants. There were no significant differences between the weight groups with respect to age, race, insurance, education, tobacco use and primigravity. Overall, 49% participants knew that obesity increases risks in pregnancy. The knowledge of specific risks was similar in the non-obese (60% correct) and obese (64% correct) groups (P¼0.76). Obese patients were more aware of the risk for diabetes (68 vs 96%, P<0.001). Obese

Background: Robust evidence to direct management of pregnant women with mild hypertensive disease at term is scarce. We investigated whether induction of labour in women with a singleton pregnancy complicated by gestational hypertension or mild pre-eclampsia reduces severe maternal morbidity. Methods: We undertook a multicentre, parallel, open-label randomised controlled trial in six academic and 32 nonacademic hospitals in the Netherlands between October, 2005, and March, 2008. We enrolled patients with a singleton pregnancy at 36–41 weeks’ gestation, and who had gestational hypertension or mild pre-eclampsia. Participants were randomly allocated in a 1:1 ratio by block randomisation with a web-based application system to receive either induction of labour or expectant monitoring. Masking of intervention allocation was not possible. The primary outcome was a composite measure of poor maternal outcome—maternal mortality, maternal morbidity (eclampsia, HELLP syndrome, pulmonary oedema, thromboembolic disease, and placental abruption), progression to severeh ypertension or proteinuria, and major post-partum haemorrhage (>1000 mL blood loss). Analysis was by intention to treat and treatment eff ect is presented as relative risk. This study is registered, number ISRCTN08132825. Findings: 756 patients were allocated to receive induction of labour (n=377 patients) or expectant monitoring (n=379). 397 patients refused randomisation but authorised use of their medical records. Of women who were randomised, 117 (31%) allocated to induction of labour developed poor maternal outcome compared with 166 (44%) allocated to expectant monitoring (relative risk 0·71, 95% CI 0·59–0·86, p<0·0001). No cases of maternal or neonatal death or eclampsia were recorded. Interpretation: Induction of labour is associated with improved maternal outcome and should be advised for women with mild hypertensive disease beyond 37 weeks’ gestation.

BACKGROUND: Amniotic-fluid embolism is a rare, but serious and often fatal maternal complication of delivery, of which the cause is unknown. We undertook an epidemiological study to investigate the association between amniotic-fluid embolism and medical induction of labour.
METHODS: We used a population-based cohort of 3 million hospital deliveries in Canada between 1991 and 2002 to assess the associations between overall and fatal rates of amniotic-fluid embolism and medical and surgical induction, maternal age, fetal presentation, mode of delivery, and pregnancy and labour complications.
FINDINGS: Total rate of amniotic-fluid embolism was 14.8 per 100,000 multiple-birth deliveries and 6.0 per 100,000 singleton deliveries (odds ratio 2.5 [95% CI 0.9-6.2]). Of the 180 cases of amniotic-fluid embolism in women with singleton deliveries during the study period, 24 (13%) were fatal. We saw no significant temporal increase in occurrence of amniotic-fluid embolism for total or fatal cases. Medical induction of labour nearly doubled the risk of overall cases of amniotic-fluid embolism (adjusted odds ratio 1.8 [1.3-2.7]), and the association was stronger for fatal cases (crude odds ratio 3.5 [1.5-8.4]). Maternal age of 35 years or older, caesarean or instrumental vaginal delivery, polyhydramnios, cervical laceration or uterine rupture, placenta previa or abruption, eclampsia, and fetal distress were also associated with an increased risk.
INTERPRETATION: Medical induction of labour seems to increase the risk of amniotic-fluid embolism. Although the absolute excess risk is low, women and physicians should be aware of this risk when making decisions about elective labour induction.

OBJECTIVE: To examine trends in the rates of hypertensive disorders in pregnancy and compare the rates of severe obstetric complications for delivery hospitalizations with and without hypertensive disorders. METHODS: We performed a cross-sectional study using the 1998 –2006 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Logistic regressions and population-attributable fractions were used to examine the effect of hypertensive disorders on severe complications. RESULTS: The overall prevalence of hypertensive disorders among delivery hospitalizations increased significantly from 67.2 per 1,000 deliveries in 1998 to 81.4 per 1,000 deliveries in 2006. Compared with hospitalizations without any hypertensive disorders, the risk of severe obstetric complications ranged from 3.3 to 34.8 for hospitalizations with eclampsia/severe preeclampsia and from 1.4 to 2.2 for gestational hypertension. The prevalence of hospitalizations with eclampsia/severe pre-eclampsia increased moderately from 9.4 to 12.4 per 1,000 deliveries (P for linear trend <0.001) during the period of study. However, these hospitalizations were associated with 38% of hospitalizations with acute renal failure and 19% or more of hospitalizations with ventilation, disseminated intravascular coagulation syndrome, pulmonary edema, puerperal cerebrovascular disorders, and respiratory distress syndrome. Overall, hospitalizations with hypertensive disorders were associated with 57% of hospitalizations with acute renal failure, 27% of hospitalizations with disseminated intravascular coagulation syndrome, and 30% or more of hospitalizations with ventilation, pulmonary edema, puerperal cerebrovascular disorders, and respiratory distress syndrome. CONCLUSION: The number of delivery hospitalizations in the United States with hypertensive disorders in pregnancy is increasing, and these hospitalizations are associated with a substantial burden of severe obstetric morbidity. LEVEL OF EVIDENCE: III

Abstract Objectives The accuracy of maternal morbidity estimates from hospital discharge data may be influenced by incomplete identification of deliveries. In maternal/ infant health studies, obstetric deliveries are often identified only by the maternal outcome of delivery code (International Classification of Diseases code = V27). We developed an enhanced delivery identification method based on additional delivery-related codes and compared the performance of the enhanced method with the V27 method in identifying estimates of deliveries as well as estimates of maternal morbidity. Methods The enhanced and standard V27 methods for identifying deliveries were applied to data from the 1998–2004 Healthcare Cost and Utilization Project Nationwide Inpatient Sample, an annual nationwide representative survey of U.S. hospitalizations. Odds ratios (ORs) and 95% confidence intervals (CIs) from logistic regression were used to examine predictors of deliveries not identified using the V27 method. Results The enhanced method identified 958,868 (3.4%) more deliveries than the 27,128,539 identified using the V27 code alone. Severe complications including major puerperal infections (OR = 3.1, 95% CI 2.8–3.4), hysterectomy (OR = 6.0, 95% CI 5.3–6.8), sepsis (OR = 11.9, 95% CI 10.3–13.6) and respiratory distress syndrome (OR = 16.6, 95% CI 14.4–19.2) were strongly associated with deliveries not identified by the V27 method. Nationwide prevalence rates of severe maternal complications were underestimated with the V27 method compared to the enhanced method, ranging from 9% underestimation for major puerperal infections to 40% underestimation for respiratory distress syndrome. Conclusion Deliveries with severe obstetric complications may be more likely to be missed using the V27 code. Researchers should be aware that selecting deliveries from hospital stay records by V27 codes alone may affect the accuracy of their findings.

OBJECTIVE: To examine trends in the rates of severe obstetric complications and the potential contribution of changes in delivery mode and maternal characteristics to these trends. METHODS: We performed a cross-sectional study of severe obstetric complications identified from the 1998– 2005 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Logistic regression was used to examine the effect of changes in delivery mode and maternal characteristics on rates of severe obstetric complications. RESULTS: The prevalence of delivery hospitalizations (per 1,000) complicated by at least one severe obstetric complication increased from 0.64% (n
48,645) in 1998– 1999 to 0.81% (n
68,433) in 2004–2005. Rates of complications that increased significantly during the study period included renal failure by 21% (from 0.23 to 0.28), pulmonary embolism by 52% (0.12 to 0.18), adult respiratory distress syndrome by 26% (0.36 to 0.45), shock by 24% (0.15 to 0.19), blood transfusion by 92% (2.38 to 4.58), and ventilation by 21 % (0.47 to 0.57). In logistic regression models, adjustment for maternal age had no effect on the increased risk for these complications in 2004–2005 relative to 1998–1999. However, after adjustment for mode of delivery, the increased risks for these complications in 2004–2005 relative to 1998–1999 were no longer significant, with the exception of pulmonary embolism (odds ratio 1.30) and blood transfusion (odds ratio 1.72). Further adjustment for payer, multiple births, and select comorbidities had little effect. CONCLUSION: Rates of severe obstetric complications increased from 1998–1999 to 2004–2005. For many of these complications, these increases were associated with the increasing rate of cesarean delivery. (Obstet Gynecol 2009;113:293–9) LEVEL OF EVIDENCE: III

Gender differences in cardiovascular disease (CVD) occurrence and prevention have been studied extensively during the past two decades.1 It is now widely recognized that women are not diagnosed as effectively or treated as aggressively as men and that with acute coronary syndrome, their symptoms may be very different from those of men.1 Although the major CVD risk factors are generally the same among men and women,2 some studies have suggested a more substantial role for diabetes and hypertension as risk factors in women compared to men.3–5 Moreover, during the last decade, it has become increasingly apparent that four common pregnancy complications, gestational diabetes, hypertensive disorders during pregnancy, low birth weight delivery, and preterm delivery, are significant CVD risk factors.6 In this issue of the Journal of Women’s Health, Making Use of a Natural Stress Test: Pregnancy and Cardiovascular Risk, by Bilhartz et al.,7 advances the idea that the history of a hypertensive disorders in pregnancy should be incorporated into models of CVD risk assessment. The authors review the substantial evidence that women with hypertensive disorders in pregnancy have a risk of developing CVD in later life that is 2–8-fold higher than that of unaffected controls. The review of the literature suggests that this risk varies by the type, time of onset, severity, and frequency of the hypertensive disorders, with women with early onset preeclampsia, severe preeclampsia, preeclampsia with preterm delivery, or recurrent preeclampsia carrying the most elevated risk. The strength of the evidence suggesting the association of hypertensive disorders in pregnancy and CVD is undeniable. The major challenge ahead for clinicians, researchers, and public health professionals, however, is to understand the basis for this association and how it should be incorporated into guidelines and preventive interventions aimed at patients with a history of hypertension in pregnancy.

Objectives To describe changes in characteristics of delivery and postpartum hospitalisations with chronic heart disease from 1995 to 2006. Design Cross-sectional study. Setting USA, nationwide hospital discharge data. Population A total of 47 882 817 delivery hospitalisations and 660 038 postpartum hospitalisations. Methods Adjusted odds ratios describing the associations between chronic maternal heart disease and severe obstetric complications were obtained from multivariable logistic models. The contribution of chronic heart disease to severe morbidity was estimated using adjusted population-attributable fractions. Main outcome measures Prevalence and trends in chronic heart disease, rate and risk of severe obstetric complications. Results In 2004–2006, about 1.4% of delivery hospitalisations were complicated with chronic heart disease. No substantial changes in the overall prevalence of chronic heart disease among hospitalisations for delivery were observed from 1995–1997 to 2004–2006. Even so, a linear increase was found for specific congenital heart disease, cardiac dysrhythmias, and cardiomyopathy and congestive heart failure (P < 0.01). During this same period the rate of postpartum hospitalisations with chronic heart disease tripled (P < 0.01). Severe complications during hospitalisations for delivery among women with chronic heart disease were more common in 2004–2006 than in 1995– 1997. In 2004–2006, 64.5% of the cases of acute myocardial infarction, 57.5% of the instances of cardiac arrest/ventricular fibrillation, 27.8% of in-hospital mortality and 26.0% of the cases of adult respiratory distress syndrome were associated with hospitalisations with chronic heart disease. Conclusions In the USA chronic heart disease among women hospitalised during pregnancy may have increased in severity from 1995 to 2006. Keywords Epidemiology, heart diseases, pregnancy.

OBJECTIVES: To estimate the rate of pregnancy hospitalizations for women with two groups of myocardial disorders, cardiomyopathy and other myocardial disorders, and report the rate of severe obstetric complications among these hospitalizations in delivery and postpartum periods. METHODS: We performed a cross-sectional study using 14,323,731 hospitalizations for pregnancy identified from the 2004–2006 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. We reported rates of pregnancy hospitalizations with cardiomyopathy and other myocardial disorders per 1,000 deliveries and rates of severe complications per 1,000 hospitalizations during delivery and postpartum periods by myocardial disease status. We compared these rates by using
2 tests with adjustment of P values for multiple comparisons using the Bonferroni method. RESULTS: Among all pregnancy hospitalizations, the overall prevalence of hospitalizations with myocardial disorders was 1.33 per 1,000 deliveries. The rate of pregnancy hospitalizations with cardiomyopathy was 0.46 per 1,000 deliveries (0.18 for apparent peripartum cardiomyopathy and 0.28 for other cardiomyopathies). The rate of pregnancy hospitalizations with other myocardial disorders was 0.87 per 1,000 deliveries. Myocardial disorders were rare during delivery hospitalizations (0.01%) but not uncommon among postpartum hospitalizations (4.2%). Among hospitalizations with myocardial disorders, the rate of severe complications ranged from 13.2 for acute myocardial infarction to 128.6 for adult respiratory distress syndrome and from 10.7 for pulmonary edema to 193.0 for fluid and electrolyte disorders per 1,000 delivery and postpartum hospitalizations, respectively. Among hospitalizations without myocardial disorders, the rate of severe complications ranged from 0.07 to 1.9 and from 0.4 to 65.5 for cardiac arrest and for fluid and electrolyte disorders per 1,000 hospitalizations, in delivery and postpartum periods, respectively. CONCLUSION: Although only a minority of hospitalizations for cardiomyopathy are consistent with peripartum cardiomyopathy, cardiomyopathy and other myocardial disorders are important contributors to severe obstetric complications. (Obstet Gynecol 2010;115:93–100) LEVEL OF EVIDENCE: III

Background and Purpose: Stroke is an important contributor to maternal morbidity and mortality, but there are no recent data on trends in pregnancy-related hospitalizations that have involved a stroke. This report describes stroke hospitalizations for women in the antenatal, delivery, and postpartum periods from 1994 to 1995 to 2006 to 2007 and analyzes the changes in these hospitalizations over time. Methods: Hospital discharge data were obtained from the Nationwide Inpatient Sample, developed as part of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. Pregnancyrelated hospitalizations with stroke were identified according to the International Classification of Diseases, Ninth Revision. All statistical analyses accounted for the complex sampling design of the data source. Results: Between 1994 to 1995 and 2006 to 2007, the rate of any stroke (subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, transient ischemic attack, cerebral venous thrombosis, or unspecified) among antenatal hospitalizations increased by 47% (from 0.15 to 0.22 per 1000 deliveries) and among postpartum hospitalizations by 83% (from 0.12 to 0.22 per 1000 deliveries) while remaining unchanged at 0.27 for delivery hospitalizations. In 2006 to 2007,
32% and 53% of antenatal and postpartum hospitalizations with stroke, respectively, had concurrent hypertensive disorders or heart disease. Changes in the prevalence of these 2 conditions from 1994 to 1995 to 2006 to 2007 explained almost all of the increase in postpartum hospitalizations with stroke during the same period. Conclusions: Our results have demonstrated an increasing trend in the rate of pregnancy-related hospitalizations with stroke in the United States, especially during the postpartum period, from 1994 to 1995 to 2006 to 2007. (Stroke. 2011; 42:2564-2570.)

Objectives. To compare the risk of postpartum infections within 30 days after vaginal birth, emergency, or elective cesarean section (CS). Design. Register-based cohort study in Denmark. Participants. A total of 32,468 women giving birth in hospitals in the County of Aarhus, Denmark, during the period 2001
2005. Methods. Data from various hospital registries were combined and infections were identified by positive cultures, prescriptions for antibiotics and, re-operative procedures. Risk of postpartum infection was estimated and adjustment for potentially confounders was performed. Results. Within 30 days postpartum, 7.6% of women who had underwent CS and 1.6% of women having a vaginal birth acquired an infection, yielding an adjusted odds ratio (OR) of 4.71, 95% confidence interval (CI): 4.08
5.43. The prevalence of postpartum urinary tract infection (UTI) was 2.8%, after CS and 1.5% after vaginal birth corresponding to an adjusted OR1.68, 95%
CI: 1.38
2.03. The risk of UTI did not differ between emergency and elective CS. The prevalence of WI was 5.0% after CS and 0.08% after vaginal birth. Moreover, we found a nearly 50% higher risk of postpartum WI after emergency CS compared to elective CS (OR1.49, 95%
CI: 1.13
1.97). More than 75% (697/907) of postpartum infections appeared after hospital discharge. Conclusions. The risk of postpartum infection seems to be nearly five-fold increased after CS compared with vaginal birth. This may be of concern since the prevalence of CS is increasing.

OBJECTIVE: To estimate trends in incidence and identify risk factors and maternal and neonatal consequences of eclampsia in Canada. METHODS: We conducted a population-based cohort study of all women and their newborns (N
1,910,729) delivered in the hospital in Canada (excluding Quebec) from 2003 to 2009. The data were obtained from the Canadian Institute for Health Information. Logistic models were used to examine the association with potential determinants and consequences of eclampsia. RESULTS: The incidence of eclampsia declined dramatically from 12.4 per 10,000 deliveries in 2003 to 5.9 in 2009. Among singleton deliveries, nulliparity (adjusted odds ratio [OR] 2.3; 95% confidence interval [CI] 2.0 –2.6), anemia (adjusted OR 2.4; 95% CI 2.0 –3.0), and existing heart disease (adjusted OR 4.8; 95% CI 2.9 –7.3) increased the risk of eclampsia. The declining trend in eclampsia remained unchanged after accounting for changes in potential determinants and risk factors during the study period. Eclampsia was associated with increased risks of maternal death (adjusted OR 26.8; 95% CI 9.7–73.8), assisted ventilation (adjusted OR 102.3; 95% CI 78.2– 133.8), respiratory distress syndrome (adjusted OR 36.2; 95% CI 15.3– 85.3), acute renal failure (adjusted OR 20.9; 95% CI 11.4 –38.3), obstetric embolism (adjusted OR 9.1; 95% CI 4.1–19.9), and other complications. Adverse neonatal outcomes associated with eclampsia included neonatal death (adjusted OR 2.9; 95% CI 1.6 –5.5), respiratory distress syndrome (adjusted OR 5.1; 95% CI 4.1– 6.3), and small-for-gestational age birth (adjusted OR 2.6; 95% CI 2.3–3.0). CONCLUSION: Despite declining incidence and improved care of women with eclampsia, the condition remains strongly associated with serious adverse consequences.

BACKGROUND: The rate of elective primary cesarean delivery continues to rise, owing in part to the widespread perception that the procedure is of little or no risk to healthy women.
METHODS: Using the Canadian Institute for Health Information's Discharge Abstract Database, we carried out a retrospective population-based cohort study of all women in Canada (excluding Quebec and Manitoba) who delivered from April 1991 through March 2005. Healthy women who underwent a primary cesarean delivery for breech presentation constituted a surrogate "planned cesarean group" considered to have undergone low-risk elective cesarean delivery, for comparison with an otherwise similar group of women who had planned to deliver vaginally.
RESULTS: The planned cesarean group comprised 46,766 women v. 2,292,420 in the planned vaginal delivery group; overall rates of severe morbidity for the entire 14-year period were 27.3 and 9.0, respectively, per 1000 deliveries. The planned cesarean group had increased postpartum risks of cardiac arrest (adjusted odds ratio [OR] 5.1, 95% confidence interval [CI] 4.1-6.3), wound hematoma (OR 5.1, 95% CI 4.6-5.5), hysterectomy (OR 3.2, 95% CI 2.2-4.8), major puerperal infection (OR 3.0, 95% CI 2.7-3.4), anesthetic complications (OR 2.3, 95% CI 2.0-2.6), venous thromboembolism (OR 2.2, 95% CI 1.5-3.2) and hemorrhage requiring hysterectomy (OR 2.1, 95% CI 1.2-3.8), and stayed in hospital longer (adjusted mean difference 1.47 d, 95% CI 1.46-1.49 d) than those in the planned vaginal delivery group, but a lower risk of hemorrhage requiring blood transfusion (OR 0.4, 95% CI 0.2-0.8). Absolute risk increases in severe maternal morbidity rates were low (e.g., for postpartum cardiac arrest, the increase with planned cesarean delivery was 1.6 per 1000 deliveries, 95% CI 1.2-2.1). The difference in the rate of in-hospital maternal death between the 2 groups was nonsignificant (p = 0.87).
INTERPRETATION: Although the absolute difference is small, the risks of severe maternal morbidity associated with planned cesarean delivery are higher than those associated with planned vaginal delivery. These risks should be considered by women contemplating an elective cesarean delivery and by their physicians.

This is the Executive Summary of updated guidelines developed by the Society of Obstetric Medicine of Australia and New Zealand for the management of hypertensive diseases of pregnancy. They address a number of challenging areas including the definition of severe hypertension, the use of automated blood pressure monitors, the definition of non-proteinuric pre-eclampsia and measuring proteinuria. Controversial management issues are addressed such as the treatment of severe hypertension and other significant manifestations of pre-eclampsia, the role of expectant management in pre-eclampsia remote from term, thromboprophylaxis, appropriate fluid therapy, the role of prophylactic magnesium sulfate and anaesthetic issues for women with pre-eclampsia. The guidelines stress the need for experienced team management for women with pre-eclampsia and mandatory hospital protocols for treatment of hypertension and eclampsia. New areas addressed in the guidelines include recommended protocols for maternal and fetal investigation of women with hypertension, preconception management for women at risk of pre-eclampsia, auditing outcomes in women with hypertensive diseases of pregnancy and long-term screening for women with previous pre-eclampsia.

Background Excessive weight gain during pregnancy seems to increase birthweight and the off spring’s risk of obesity later in life. However, this association might be confounded by genetic and other shared eff ects. We aimed to examine the association between maternal weight gain and birthweight using state-based birth registry data that allowed us to compare several pregnancies in the same mother. Methods In this population-based cohort study, we used vital statistics natality records to examine all known births in Michigan and New Jersey, USA, between Jan 1, 1989, and Dec 31, 2003. From an initial sample of women with more than one singleton birth in the database, we made the following exclusions: gestation less than 37 weeks or 41 weeks or more; maternal diabetes; birthweight less than 500 g or more than 7000 g; and missing data for pregnancy weight gain. We examined how differences in weight gain that occurred during two or more pregnancies for each woman predicted the birthweight of her off spring, using a within-subject design to reduce confounding to a minimum. Findings Our analysis included 513 501 women and their 1 164 750 off spring. We noted a consistent association between pregnancy weight gain and birthweight (β 7·35, 95% CI 7·10–7·59, p<0·0001). Infants of women who gained more than 24 kg during pregnancy were 148·9 g (141·7–156·0) heavier at birth than were infants of women who gained 8–10 kg. The odds ratio of giving birth to an infant weighing more than 4000 g was 2·26 (2·09–2·44) for women who gained more than 24 kg during pregnancy compared with women who gained 8–10 kg. Interpretation Maternal weight gain during pregnancy increases birthweight independently of genetic factors. In view of the apparent association between birthweight and adult weight, obesity prevention eff orts targeted at women during pregnancy might be benefi cial for off spring.

OBJECTIVE: Because postpartum hemorrhage may result from factors related to obstetrical practice patterns, we examined the variability of postpartum hemorrhage and related risk factors (obstetrical trauma, chorioamnionitis, and protracted labor) across hospital types and hospitals in California.
METHODS: Linked birth certificate and hospital discharge data from 507,410 births in California in 1997 were analyzed. Cases were identified using International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes. Comparisons were made across hospital types and individual hospitals. Risk adjustments were made using 1) sample restriction to a subset of 324,671 low-risk women, and 2) Bayesian hierarchical logistic regression model to simultaneously quantify the effects of patient-level and hospital-level risk factors.
RESULTS: Postpartum hemorrhage complicated 2.4% of live births. The incidence ranged from 1.6% for corporate hospitals to 4.9% for university hospitals in the full sample, and from 1.4% for corporate hospitals to 3.9% for university hospitals in the low-risk sample. Low-risk women who delivered at government, HMO and university hospitals had two- to threefold increased odds (odds ratios 1.98 to 2.71; 95% confidence sets ranged from 1.52 to 4.62) of having postpartum hemorrhage compared to women who delivered at corporate hospitals, irrespective of patient-level characteristics. They also had significantly higher rates of obstetrical trauma and chorioamnionitis. Greater variations were observed across individual hospitals.
CONCLUSION: The incidence of postpartum hemorrhage and related risk factors varied substantially across hospital types and hospitals in California. Further studies using primary data sources are needed to determine whether these variations are related to the processes of care.

Our objective was to study the effects of maternal body mass index (BMI) on the mode of delivery for primigravid and multigravid women. A retrospective cohort study was conducted at the University College Hospital Galway, Ireland, of 5162 women delivered from 2001 to 2003. BMI at the first antenatal appointment was calculated. Comparisons were made between each of the five BMI categories separately for primigravid and multigravid women in relation to gestation at delivery, age, mode of delivery, and birthweight. There were 5162 deliveries during the time period of the study; 2006 were primigravid and 3156 were multigravid women. Overall, 2.6% of women were underweight, 49.2% were normal weight, 22.8% were overweight, 19.8% were obese, and 5.6% were morbidly obese. In comparison with women of normal weight, for overweight and obese women, there was a progressive reduction in vaginal delivery rate with increasing BMI. For morbidly obese primigravida, this reduction was by 33.5% (from 83.1% to 55.3%, x2¼39.84, p<0.001), and for multigravida was by 23.6% (from 86% to 65.7%, x2¼53.05, p<0.001). Obesity conferred a two- to threefold increased risk of delivery by emergency caesarean section for both primigravid (obese, relative risk [RR] 2.16, 95% confidence interval [CI] 1.72 to 2.73; morbidly obese, RR 2.30, CI 1.61 to 3.37) and multigravid women (obese, RR 1.97, CI 1.45 to 2.67; morbidly obese, RR 2.44, CI 1.61 to 3.69). We concluded that increasing maternal BMI exerts a progressive adverse effect on vaginal delivery rates for both primigravid and multigravid women. Obese primigravida should be counseled antenatally about the 30% risk of emergency caesarean section.

Abstract Objective: This guideline summarizes the quality of the evidence to date and provides a reasonable approach to the diagnosis, evaluation, and treatment of the hypertensive disorders of pregnancy (HDP). Evidence: The literature reviewed included the original HDP guidelines and their reference lists and an update from 1995. Using key words, Medline was searched for literature published between 1995 and 2007. Articles were restricted to those published in French or English. Recommendations were evaluated using the criteria of the Canadian Task Force on Preventive Health Care (Table 1). Sponsors: This guideline was developed by the Society of Obstetricians and Gynaecologists of Canada and was partly supported by an unrestricted educational grant from the British Columbia Perinatal Health Program (formerly the British Columbia Reproductive Care Program or BCRCP). The Canadian Hypertension Society provided assistance with the literature search and some travel support for one author.

Background: Anticonvulsants are used for pre-eclampsia in the belief they prevent eclamptic convulsions, and so improve outcome. Evidence supported magnesium sulphate as the drug to evaluate. Methods: Eligible women (n=10 141) had not given birth or were 24 h or less postpartum; blood pressure of 140/90 mm Hg or more, and proteinuria of 1+ (30 mg/dL) or more; and there was clinical uncertainty about magnesium sulphate. Women were randomised in 33 countries to either magnesium sulphate (n=5071) or placebo (n=5070). Primary outcomes were eclampsia and, for women randomised before delivery, death of the baby. Follow up was until discharge from hospital after delivery. Analyses were by intention to treat. Findings: Follow-up data were available for 10 110 (99·7%) women, 9992 (99%) of whom received the allocated treatment. 1201 of 4999 (24%) women given magnesium sulphate reported side-effects versus 228 of 4993 (5%) given placebo. Women allocated magnesium sulphate had a 58% lower risk of eclampsia (95% CI 40–71) than those allocated placebo (40, 0·8%, vs 96, 1·9%; 11 fewer women with eclampsia per 1000 women). Maternal mortality was also lower among women allocated magnesium sulphate (relative risk 0·55, 0·26–1·14). For women randomised before delivery, there was no clear difference in the risk of the baby dying (576, 12·7%, vs 558, 12·4%; relative risk 1·02, 99% CI 0·92–1·14). The only notable difference in maternal or neonatal morbidity was for placental abruption (relative risk 0·67, 99% CI 0·45–0·89). Interpretation Magnesium sulphate halves the risk of eclampsia, and probably reduces the risk of maternal death. There do not appear to be substantive harmful effects to mother or baby in the short term.

OBJECTIVE: To determine whether obstetric admissions to the intensive care unit (ICU) are useful quality-assurance indicators.
METHODS: We analyzed retrospectively obstetric ICU admissions at two tertiary care centers from 1991 to 1997.
RESULTS: The 131 obstetric admissions represented 0.3% of all deliveries. The majority (78%) of women were admitted to the ICU postpartum. Obstetric hemorrhage (26%) and hypertension (21%) were the two most common reasons for admission. Together with cardiac disease, respiratory disorders, and infection, they accounted for more than 80% of all admissions. Preexisting medical conditions were present in 38% of all admissions. The median Acute Physiology and Chronic Health Evaluation II score was 8.5. The predicted mortality rate for the group was 10.0%, and the actual mortality rate was 2.3%.
CONCLUSION: The most common precipitants of ICU admission were obstetric hemorrhage and uncontrolled hypertension. Improved management strategies for these problems may significantly reduce major maternal morbidity.

OBJECTIVE: To estimate the efficacy of acupuncture for depression during pregnancy in a randomized controlled trial. METHODS: A total of 150 pregnant women who met Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria for major depressive disorder were randomized to receive either acupuncture specific for depression or one of two active controls: control acupuncture or massage. Treatments lasted 8 weeks (12 sessions). Junior acupuncturists, who were not told about treatment assignment, needled participants at points prescribed by senior acupuncturists. All treatments were standardized. The primary outcome was the Hamilton Rating Scale for Depression, administered by masked raters at baseline and after 4 and 8 weeks of treatment. Continuous data were analyzed using mixed effects models and by intent to treat. RESULTS: Fifty-two women were randomized to acupuncture specific for depression, 49 to control acupuncture, and 49 to massage. Women who received acupuncture specific for depression experienced a greater rate of decrease in symptom severity (P<.05) compared with the combined controls (Cohen’s d
0.39, 95% confidence interval [CI] 0.01– 0.77) or control acupuncture alone (P<.05; Cohen’s d
0.46, 95% CI 0.01– 0.92). They also had significantly greater response rate (63.0%) than the combined controls (44.3%; P<.05; number needed to treat, 5.3; 95% CI 2.8 –75.0) and control acupuncture alone (37.5%; P<.05: number needed to treat, 3.9; 95% CI 2.2–19.8). Symptom reduction and response rates did not differ significantly between controls (control acupuncture, 37.5%; massage, 50.0%). CONCLUSION: The short acupuncture protocol demonstrated symptom reduction and a response rate comparable to those observed in standard depression treatments of similar length and could be a viable treatment option for depression during pregnancy. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, www.clinicaltrials.gov, NCT00186654. (Obstet Gynecol 2010;115:511–20) LEVEL OF EVIDENCE: I

Pulmonary embolism and deep-vein thrombosis are the two components of a single disease called venous thromboembolism. Approximately 30% of apparently isolated episodes of pulmonary embolism are associated with silent deep-vein thrombosis, and in patients presenting with symptoms of deep-vein thrombosis, the frequency of silent pulmonary embolism ranges from 40 to 50%.1,2 Venous thromboembolism is both more common and more complex to diagnose in patients who are pregnant than in those who are not pregnant. The incidence of venous thromboembolism is estimated at 0.76 to 1.72 per 1000 pregnancies, which is four times as great as the risk in the nonpregnant population.3,4 A meta-analysis showed that two thirds of cases of deep-vein thrombosis occurred in the antepartum period and were distributed relatively equally among all three trimesters.5 In contrast, 43 to 60% of pregnancy-related episodes of pulmonary embolism appear to occur in the puerperium.4,6,7 Pulmonary embolism is the leading cause of maternal death in the developed world. Current estimates of deaths from pulmonary embolism are 1.1 to 1.5 per 100,000 deliveries in the United States and Europe.4,8,9 In the United Kingdom, venous thromboembolism accounts for one third of all maternal deaths.8,9 Delayed diagnosis, delayed or inadequate treatment, and inadequate thromboprophylaxis account for many of the deaths due to venous thromboembolism.8,9 Successful strategies for the management of venous thromboembolism in nonpregnant patients have been established. However, many of the recommendations for the treatment of pregnant patients who have venous thromboembolism are not based on high-quality data; rather, they are derived from observational studies and extrapolation from studies involving nonpregnant patients. The purpose of this review is to provide a practical approach to the diagnosis, management, and prevention of venous thromboembolism in pregnant patients.

OBJECTIVE: This study was undertaken to investigate the utility of an admission battery of findings and laboratory data in the discrimination of patients with severe preeclampsia with or without HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome at high risk for development of significant maternal morbidity. STUDY DESIGN: The clinical and laboratory findings at hospital admission for 970 patients with severe preeclampsia with or without HELLP syndrome were studied retrospectively to develop parameters associated with low, moderate, and high risks for the subsequent development of significant maternal morbidity involving the hematologic and coagulation, cardiopulmonary, and hepatorenal systems. RESULTS: Nausea and vomiting and epigastric pain are independent risk factors for complicated severe preeclampsia. Results of a panel of tests with values including lactate dehydrogenase level >1400 IU/L, aspartate aminotransferase level >150 IU/L, alanine aminotransferase level >100 IU/L, uric acid level >7.8 mg/dL, serum creatinine level >1.0 mg/dL, and 4+ urinary protein by dipstick can be used to discriminate the patient at high risk for significant maternal morbidity. Concentrations of lactate dehydrogenase, aspartate aminotransferase, and uric acid above these cut points have the strongest predictive value and are risk additive with worsening thrombocytopenia. CONCLUSION: The presence of nausea and vomiting, epigastric pain, or both in association with admission laboratory values that are in excess of the cutoffs for lactate dehydrogenase, aspartate aminotransferase, and uric acid concentrations or for all 6 tests is predictive of high risk of morbidity for the patient with severe preeclampsia. These factors are independent of and additive with the rising maternal risk associated with decreasing platelet count.

Objective. To evaluate the effectiveness of the Mississippi Protocol (MP) to treat HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. Methods. Uniform early initiation of MP (corticosteroids, magnesium sulfate, systolic blood pressure control) was studied prospectively in patients admitted with severe preeclampsia/ class 1 or class 2 HELLP syndrome. Results. One hundred and ninety patients between 2000 and 2007 received MP without suffering maternal death, stroke, or liver rupture. Only 39 of 163 patients (24%) not class 1 when MP began progressed to class 1 disease; only 18.2% of class 1 and 2.4% of class 2 subsequently developed major maternal morbidity. Conclusion. Early initiation of MP inhibits HELLP syndrome disease progression and severity.

Antepartum or postpartum HELLP syndrome constitutes an obstetric emergency that requires expert knowledge and management skills. The insidious and variable nature of disease presentation and progression challenges the clinician and complicates consensus on universally accepted diagnostic and classification criteria. A critical review of published research about this variant form of severe preeclampsia, focused primarily on what is known about the pathogenesis of this disorder as it relates to patient experience with corticosteroids for its management, leads to the conclusion that there is maternal-fetal benefit realized when potent glucocorticoids are aggressively used for its treatment. Although acknowledging the need for definitive multicenter trials to better define the limits of benefit and the presence of any maternal or fetal risk, and given an understanding of the nature of the disorder with its potential to cause considerable maternal morbidity and mortality, we recommend for the present that aggressively used potent glucocorticoids constitute the cornerstone of management for patients considered to have HELLP syndrome.

OBJECTIVE: We compared maternal outcomes for patients with HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome treated with or without high-dose corticosteroids to ameliorate maternal disease. STUDY DESIGN: An analysis of data for patients with HELLP syndrome (platelets, #100,000/lL; lactate dehydrogenase level, $600 IU/L; aspartate aminotransferase and/or alanine aminotransferase level, $70 IU/L) who were treated during the 7-year epochs before and after the clinical trials in 1992 and 1993 demonstrated maternal benefit with high-dose dexamethasone. RESULTS: Corticosteroid use increased from 16% (39/246 patients) for fetal indication from 1985 to 1991 to 90% (205/228 patients) for maternal-fetal indications from 1994 to 2000. Significantly reduced composite maternal disease from 1994 to 2000 was evidenced by improvements in laboratory parameters, disease progression to class 1 HELLP syndrome, the degree of hypertension, the need for antihypertensive therapy, the use of transfusion, and the presence of maternal morbidity (P < .05). Indices of postpartum recovery also were shortened significantly (P < .001). CONCLUSION: Routine early initiation of high-dose intravenous corticosteroids for patients with HELLP syndrome significantly lessened maternal disease, reduced maternal morbidity, and expedited recovery.

Abstract Recent studies suggest that the risk of cerebral infarction is increased during the puerperium but not during pregnancy itself. Most of the known causes of ischaemic stroke in the young have been reported during pregnancy. In most of these conditions, it is uncertain whether pregnancy is coincidental or plays a role in the occurrence of stroke. Eclampsia is the main pregnancy-specific cause, which may be associated with focal neurological deficits of sudden onset, consistent with a clinical diagnosis of stroke. However, the precise pathogenesis of these stroke-like focal deficits remains poorly understood. The two other pregnancy-specific conditions (choriocarcinoma and amniotic fluid embolism) are rarely responsible for focal cerebral ischaemia. In a significant number of patients, the cause of the stroke remains undetermined, despite an extensive aetiological investigation. Whether a hypercoagulable state and vessel wall changes associated with pregnancy may play a role in the occurrence of these otherwise unexplained ischaemic strokes remains unknown. The occurrence of cerebral venous thrombosis is clearly linked to the puerperal state, suggesting a direct role of the latter. However, cerebral venous thrombosis during pregnancy or the puerperium has been related to various aetiologies, stressing the need for an aetiological study, particularly when the thrombosis occurs during pregnancy. Pregnancy may increase the risk of subarachnoid haemorrhage, The most common cause is rupture of an arterial aneurysm. Although this is a controversial issue, the increased tendency of an aneurysm to bleed with advancing gestational age suggests that haemodynamic, hormonal or other physiological changes of pregnancy may play a role in aneurysmal rupture. The classic notion that rupture of an arterial aneurysm occurs more frequently during labour has not been confirmed. Most authors agree that surgical management after subarachnoid haemorrhage in pregnancy should be the same as that in the non-pregnant state. Data specifically devoted to intraparenchymal haemorrhage in pregnancy are scarce. Pregnancy and in particular the puerperium seem to be associated with an increased risk of intracerebral haemorrhage. The most common causes are eclampsia and ruptured vascular malformations. Whether pregnancy increases the risk of rupture of an arteriovenous malformation is controversial.

Preeclampsia, a hypertensive disorder peculiar to pregnancy, is a systemic syndrome that appears to originate in the placenta and is characterized by widespread maternal endothelial dysfunction. Until recently, the molecular pathogenesis of phenotypic preeclampsia was largely unknown, but recent observations support the hypothesis that altered expression of placental anti-angiogenic factors are responsible for the clinical manifestation of the disease. Soluble Flt1 and soluble endoglin, secreted by the placenta, are increased in the maternal circulation weeks before the onset of preeclampsia. These anti-angiogenic factors produce systemic endothelial dysfunction, resulting in hypertension, proteinuria, and the other systemic manifestations of preeclampsia. The molecular basis for placental dysregulation of these pathogenic factors remains unknown, and as of 2010 the role of angiogenic proteins in early placental vascular development was starting to be explored. The data linking angiogenic factors to preeclampsia have exciting clinical implications, and likely will transform the detection and treatment of preeclampsia.

Objective: To examine the association between obesity subtypes and risk of early and late pre-eclampsia. Design: Population-based retrospective study. Setting: State of Missouri maternally linked birth cohort files. Population: All singleton live births in the state of Missouri from 1989 to 2005. Methods: The body mass index (BMI) was used to classify women as normal weight (BMI = 18.5–24.9 kg/m2), class I obesity (BMI = 30–34.9 kg/m2), class II obesity (BMI = 35–39.9 kg/m2), class III obesity (BMI = 40–49.9 kg/m2) or super-obesity (BMI ‡ 50 kg/m2). Adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between obesity and the risk of pre-eclampsia were obtained from logistic regression models with adjustment for intracluster correlation. Results: The rate of pre-eclampsia increased with increasing BMI, with super-obese women having the highest incidence (13.4%). Compared with normal weight women, obese women (BMI ‡ 30 kg/m2) had a higher risk for pre-eclampsia (OR = 2.59, 95% CI = 2.87–3.01). This risk remained approximately the same for late-onset pre-eclampsia (preeclampsia occurring at 34 weeks or more of gestation) and was slightly reduced for early-onset pre-eclampsia (pre-eclampsia occurring at 34 weeks or less of gestation). Within each BMI category, the risk of pre-eclampsia increased with the rate of weight gain. Compared with normal weight mothers with moderate weight gain, super-obese women with a high rate of weight gain had the greatest risk for pre-eclampsia (OR = 7.52, 95% CI = 2.70–21.0). Conclusion: BMI and rate of weight gain are synergistic risk factors that amplify the burden of pre-eclampsia among super-obese women.

ABSTRACT Objective To determine the relation between overweight and obesity in mothers and preterm birth and low birth weight in singleton pregnancies in developed and developing countries. Design Systematic review and meta-analyses. Data sources Medline and Embase from their inceptions, and reference lists of identified articles. Study selection Studies including a reference group of women with normal body mass index that assessed the effect of overweight and obesity on two primary outcomes: preterm birth (before 37 weeks) and low birth weight (<2500 g). Data extraction Two assessors independently reviewed titles, abstracts, and full articles, extracted data using a piloted data collection form, and assessed quality. Data synthesis 84 studies (64 cohort and 20 casecontrol) were included, totalling 1 095 834 women. Although the overall risk of preterm birth was similar in overweight and obese women and women of normal weight, the risk of induced preterm birth was increased in overweight and obese women (relative risk 1.30, 95% confidence interval 1.23 to 1.37). Although overall the risk of having an infant of low birth weight was decreased in overweight and obese women (0.84, 0.75 to 0.95), the decrease was greater in developing countries than in developed countries (0.58, 0.47 to 0.71 v 0.90, 0.79 to 1.01). After accounting for publication bias, the apparent protective effect of overweight and obesity on low birth weight disappeared with the addition of imputed “missing” studies (0.95, 0.85 to 1.07), whereas the risk of preterm birth appeared significantly higher in overweight and obese women (1.24, 1.13 to 1.37). Conclusions Overweight and obese women have increased risks of preterm birth and induced preterm birth and, after accounting for publication bias, appeared to have increased risks of preterm birth overall. The beneficial effects of maternal overweight and obesity on low birth weight were greater in developing countries and disappeared after accounting for publication bias. INTRODUCTION The continuum of overweight and obesity is now the most common complication of pregnancy in many developed and some developing countries. In the United Kingdom, 33% of pregnant women are overweight or obese.1 In the United States, 12%2 to 38%3 of pregnant women are overweight and 11%4 to 40%3 are obese. In India, 8% of pregnant women are obese and 26% are overweight5 and in China, 16% are overweight or obese.6 Pretermbirth is the leading cause of neonatal mortality and morbidity and childhood morbidity7 followed by low birth weight.8 Whether maternal overweight and obesity is associated with increased,9 decreased,10 or neutral risks11 of preterm birth has been debated in the literature, with the uncertainty reflected in the American College of Obstetrics andGynecologyCommittee opinion on obesity in pregnancy.12 Even low birth weight, which is typically thought to be reduced in infants of overweight and obese women,3 is sometimes associated with neutral risks.5 To accurately risk stratify a pregnancy at the first antenatal visit, as is standard, it is important to know the effect of overweight and obesity in mothers on preterm birth and low birth weight.We therefore undertook a systematic, comprehensive, and unbiased accumulation and summary of the available evidence from all study designs with a reference group of normal weightwomen to determine the direction andmagnitude of the association of maternal overweight and obesity with preterm birth and low birth weight in singleton pregnancies in developed and developing countries. METHODS We carried out a systematic review and meta-analyses in accordance with the Meta-analysis Of Observational Studies in Epidemiology consensus statement.13 With the help of a librarian we searched Medline (1950 to 2 January 2009) and Embase (1980 to 2 January 2009), using individual comprehensive search strategies. This study was part of a constellation of systematic reviews examining maternal anthropometry and preterm birth and low birth weight (see search strategy in web extra appendix 1). Additional eligible studies were sought by reviewing the reference lists of identified articles.

OBJECTIVE: To estimate the success rates and risks of an attempted vaginal birth after cesarean delivery (VBAC) according to the number of prior successful VBACs.
METHODS: From a prospective multicenter registry collected at 19 clinical centers from 1999 to 2002, we selected women with one or more prior low transverse cesarean deliveries who attempted a VBAC in the current pregnancy. Outcomes were compared according to the number of prior VBAC attempts subsequent to the last cesarean delivery.
RESULTS: Among 13,532 women meeting eligibility criteria, VBAC success increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%, and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively (P<.001). The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52% (P=.03). The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter.
CONCLUSION: Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy.
LEVEL OF EVIDENCE: II.

In 2003, the 4 million hospitalizations for women giving birth accounted for 11 percent of all stays in U.S. community hospitals. The average charge for these hospitalizations was $8,300, with aggregate annual charges (i.e., the national bill) totaling over $33 billion. Charges varied greatly depending on the mode of delivery (vaginal versus C-section) and the presence of complications. For example, charges for C-sections with complications averaged $15,500, which is 2.5 times the mean charge for uncomplicated vaginal births. The mean length of stay (LOS) for all deliveries was 2.6 days. The amount of time women remained hospitalized following delivery also varied greatly, ranging from 2.1 days for uncomplicated vaginal deliveries to 4.6 days for C-sections with complications.

Background: Maternal morbidity and mortality are increased in the United States compared with that of other developed countries. The objective of this investigation is to determine the extent to which it is possible to predict which patients will experience near-miss morbidity or mortality. Methods: The authors defined near-miss morbidity as end-organ injury associated with length of stay greater than the 99th percentile or discharge to a second medical facility, and identified all cases of near-miss morbidity or death from admissions for delivery in the 2003–2006 Nationwide Inpatient Sample. Logistic regression was used to examine the effect of maternal characteristics on rates of near-miss morbidity/mortality. Results: Approximately 1.3 per 1,000 hospitalizations for delivery was complicated by near-miss morbidity/mortality as defined in this study (95% CI 1.3–1.4). Most of these events (58.3%) occurred in 11.8% of the delivering population—in those women with important medical comorbidities or obstetric complications identified before admission for delivery. The highest rates were noted among women with pulmonary hypertension (98.0 cases per 1,000 deliveries), malignancy (23.4 per 1,000), and systemic lupus erythematosus (21.1 per 1,000). Conclusions: Risk for near-miss morbidity or mortality is substantially increased among an identifiable subset of pregnant women. To the extent that antepartum multidisciplinary coordination and high-quality intrapartum care improve delivery outcomes for women with significant antepartum medical and obstetric disease, then public health investments to reduce the national burden of delivery-related near-miss morbidity and mortality will have the greatest effect by focusing resources on identifying and serving these high-risk groups.

Abstract Although screening for perinatal depression substantially improves detection, screening alone does not improve treatment entry or outcome. This paper summarizes a pilot evaluation of the feasibility and patient acceptance of on-site diagnostic assessment in perinatal care settings for women who screen positive for perinatal depressive symptoms. The model included screening, assessment by the perinatal care provider, an algorithm to guide decisions, guidelines for evidence-based antidepressant treatment, support through phone and webbased consultation, and quality monitoring to track and remedy “missed opportunities” for screening and assessment. A mean of 17.1% of women screened were identified as having depressive symptoms in need of further assessment. Of those identified, a mean of 72.0% received a diagnostic assessment on site. A mean of 1.4% of patients refused onsite diagnostic assessment. It is feasible to incorporate assessment for depression into perinatal care. This paves the way for better engagement in treatment, and better clinical outcomes.

INCIDENCE: Amniotic fluid embolism is a catastrophic syndrome that occurs during pregnancy or in the immediate postpartum period. Multiple case reports have described the clinical findings and have reported variable success with supportive care. There has been discrepancy with respect to the incidence and mortality of amniotic fluid embolism. One likely explanation for this inconsistency is the lack of sensitive and specific diagnostic studies to definitively identify cases of amniotic fluid embolism, leading to both over- and underreporting. Despite the variation in reported incidence and mortality, amniotic fluid embolism remains a life-threatening condition with significant morbidity and mortality for the pregnant woman. It is the fifth most common cause of maternal mortality in the world.
DIAGNOSIS: The diagnosis of amniotic fluid embolism continues to be a clinical diagnosis and a diagnosis of exclusion based on the rapid development of a complex constellation of findings with sudden cardiovascular collapse, acute left ventricular failure with pulmonary edema, disseminated intravascular coagulation, and neurologic impairment. Given the significant morbidity and mortality associated with this condition, a high index of suspicion is warranted. Suspected risk factors have included tumultuous labor, trauma, multiparity, increased gestational age, and increased maternal age. However, many patients who develop amniotic fluid embolism have no obvious risk factors.
MANAGEMENT: Patients with amniotic fluid embolus are best managed using a multidisciplinary approach. There are no pharmacologic or other therapies that prevent or treat the amniotic fluid embolism syndrome, and supportive care typically involves aggressive treatment of multiple types of shock simultaneously. In this article we discuss the clinical presentation of amniotic fluid embolism syndrome as well as current opinions regarding pathophysiology, diagnosis, and management.

Objective: To assess the prevalence and causes of severe maternal morbidity in Dublin over a two year period from 2004 to 2005. Study design: A prospective cohort study from January 2004 to December 2005 was undertaken in the three large maternity hospitals in Dublin, which serve a population of 1.5 million people. All are tertiary referral centres for obstetrics and neonatology and have an annual combined delivery rate of circa 23,000 births. Cases of severe maternal morbidity were identified. A systems based classification was used. The primary cause of maternal morbidity and the number of events experienced per patient was recorded. Results: We identified 158 women who fulfilled the definition for severe maternal morbidity, giving a rate of 3.2 per 1000maternities. There were two maternal deaths during the time period givingmortality to morbidity ratio of 1:79. The commonest cause of severe morbidity was vascular dysfunction related to obstetric haemorrhage. Eclampsia comprised 15.4% of cases. Intensive care or coronary care admission occurred in 12% of cases. Conclusion: The prevalence of severe maternal morbidity in this population is 3.2/1000 maternities. Obstetric haemorrhage was the main cause of severe maternal morbidity.

OBJECTIVE: The objective was to investigate the incidence, indications, and risk factors of peripartum emergent hysterectomy.
METHOD: Fifty-nine cases of emergent peripartum hysterectomy performed at Zeynep Kamil Women and Children's Education and Research Hospital during a 13-year period between January 1990 and January 2003 were evaluated retrospectively. Emergent peripartum hysterectomy was defined as that performed for haemorrhage unresponsive to other therapeutic interventions within the first 24 h of delivery.
RESULT: Emergent peripartum hysterectomy was performed in 59 cases of 234,958 women (25.1/100,000). Total and subtotal hysterectomy was performed in 25 and 34 cases respectively. The rates of emergent peripartum hysterectomy after vaginal and caesarean deliveries were 8.7/100,000 and 104.5/100,000 respectively. Uterine atony was the most frequent indication (62.7%). The rates of emergent peripartum hysterectomy due to uterine atony in primiparous and multiparous women were 61.1 and 65.2% respectively. The rate of maternal mortality was 8% (5 cases).
CONCLUSION: Uterine atony was the most common indication for emergent peripartum hysterectomy.

Objective. To define the rate of severe maternal morbidity in different modes of delivery and to find out if the rate of severe morbidity has changed over a 5-year time span. Design. Retrospective register-based study. Setting. Finnish Medical Birth Registry and Hospital Discharge Registry. Population. All singleton deliveries in Finland in 1997 and 2002 (n
110,717). Methods. Diagnoses and operative interventions recorded in the Hospital Discharge Registry indicating a severe maternal complication were linked with Birth Register data and compared by mode of delivery: spontaneous vaginal delivery (VD), instrumental VD, elective cesarean section and non-elective cesarean section. Main outcome measures were severe maternal morbidity: deep venous thromboembolism and amniotic fluid embolism, major puerperal infection, severe hemorrhage, events requiring operative intervention after delivery, uterine rupture and inversion, and intestinal obstruction. Results. Severe maternal morbidity was more frequent in cesarean than vaginal deliveries (pB0.001), and more frequent in nonelective than in elective operations (pB0.001). The rate of severe maternal morbidity increased considerably from 1997 to 2002; from 5.9 to 7.6 per 1,000 in all deliveries (pB0.001), from 4.0 per 1,000 to 5.2 per 1,000 in spontaneous vaginal deliveries (p
0.005), from 9.9 per 1,000 to 12.1 per 1,000 in elective cesarean sections (CSs) (p
0.164), and from 19.6 per 1,000 to 27.2 per 1,000 in non-elective CSs (p
0.090), respectively. Conclusions. Severe maternal morbidity has increased both in cesarean and vaginal deliveries from 1997 to 2002. Cesarean delivery, even an elective one, carries a significantly higher risk of life-threatening maternal complications than VD.

BACKGROUND: During childbirth, the maternal need for intensive care unit (ICU) services is not well-defined. This information could influence the decision whether to incorporate ICU services into the labor and delivery suite.
METHODS: This study reports (1) ICU use and mortality rates in a statewide population of obstetric patients during their hospital admission for childbirth, and (2) the risk factors associated with ICU admission and mortality. A case-control design using patient records from a state-maintained anonymous database for the years 1984-1997 was used. Outcome variables included ICU use and mortality rates.
RESULTS: Of the 822,591 hospital admissions for delivery of neonates during the study period, there were 1,023 ICU admissions (0.12%) and 34 ICU deaths (3.3%). Age, race, hospital type, volume of deliveries, and source of admission independently and in combination were associated with ICU admission (P < 0.05). The most common risk factors associated with ICU admission included cesarean section, preeclampsia or eclampsia, and postpartum hemorrhage (P < 0.001). Black race, high hospital volume of deliveries, and longer duration of ICU stay were associated with ICU mortality (P < 0.05). The most common risk factors associated with ICU mortality included pulmonary complications, shock, cerebrovascular event, and drug dependence (P < 0.05).
CONCLUSIONS: This study shows that ICU use and mortality rate during hospital admission for delivery of a neonate is low. These results may influence the location of perinatal ICU services in the hospital setting.

Abstract We investigated the association between 2009 IOM recommendations and adverse infant outcomes by maternal prepregnancy body mass index (BMI). Birth outcomes for 570,672 women aged 18–40 years with a singleton full-term live-birth were assessed using 2004–2007 Florida live-birth certificates. Outcomes included large-for-gestational-age (LGA) and small-for-gestationalage (SGA). Associations between gestational weight change and outcomes were assessed for 10 BMI groups by calculating proportions, and logistic regression modeling was used to produce adjusted odds ratios (aORs) to account for the effect of confounders. We created comparison categories below and above recommendations using 2009 IOM recommendations as a reference. Of importance, 41.6% of women began pregnancy as overweight and obese and 51.2% gained weight excessively during pregnancy on the basis of 2009 IOM recommendations. Proportions of LGA were higher among obese women and increased with higher weight gain. Compared with recommended weight gain, aORs for LGA were lower with less than recommended gain (aOR range: 0.27–0.77) and higher with more than recommended gain (aOR range: 1.27–5.99). However, SGA was less prevalent among obese women, and the proportion of SGA by BMI was similar with higher weight gain. Gain less than recommended was associated with increased odds of SGA (aOR range: 1.11–2.97), and gain greater than recommended was associated with decreased odds of SGA (aOR range: 0.38–0.83). Gestational weight gain influenced the risk for LGA and SGA in opposite directions. Minimal weight gain or weight loss lowered risk for LGA among obese women. Compared with 1990 IOM recommendations, 2009 recommendations include weight gain ranges that are associated with lower risk of LGA and higher risk of SGA. Awareness of these tradeoffs may assist with clinical implementation of the 2009 IOM gestational weight gain recommendations. However, our results did not consider other maternal and infant outcomes related to gestational weight gain; therefore, the findings should be interpreted with caution.

OBJECTIVE: To assess whether severe acute maternal morbidity (SAMM, 'near misses') can be used as a surrogate of an analysis of maternal deaths to describe the pattern of severe maternal disease and avoidable factors related to it.
DESIGN: Prospective, descriptive study.
SETTING: A SAMM and maternal mortality audit was conducted in three clearly defined geographical areas, consisting of rural and urban settings in South Africa.
POPULATION: Indigent black African pregnant women.
METHOD: Cases of SAMM and maternal deaths were collected in the areas and a comparison was made of the disease profiles and avoidable factors, missed opportunities and substandard care.
MAIN OUTCOME MEASURES: The proportion of primary obstetric causes and avoidable factors in women with SAMM and maternal deaths, and the mortality indices of the primary obstetric causes of death and organ system dysfunction.
RESULTS: A total of 423 women with SAMM and 128 maternal deaths were collected over two years. Demographic factors were similar between the groups except that significantly more maternal deaths had not attended any antenatal care. The primary obstetric causes of SAMM and maternal death did not correlate. The four most common causes of SAMM were complications of hypertension (27.2%), postpartum haemorrhage (18.0%), antepartum haemorrhage (12.8%) and abortion (11.3%), whereas the four most common causes of maternal death were non-pregnancy related sepsis (26.6%), complications of hypertension (23.4%), pre-existing medical disease (14.1%) and abortion (10.9%). The types of avoidable factors were similar between both groups although administrative factors occurred significantly more frequently in the maternal death group as did poor problem identification and monitoring.
CONCLUSION: Review of SAMM gives a different disease pattern to that obtained from maternal death audits. However, in diagnosing inadequacies in the health system, similar information was obtained.

In developed countries where maternal death is rare, the factors surrounding the death are often peculiar to the event and are not generalizable, making analysis of maternal deaths less useful. Near misses are defined as pregnant women with severe life-threatening conditions who nearly die but, with good luck or good care, survive. Incorporation of near misses into maternal death enquiries would strengthen these audits by allowing for more rapid reporting, more robust conclusions, comparisons to be made with maternal deaths, reinforcing lessons learnt, establishing requirements for intensive care and calculating comparative indices. The survival of a pregnant woman is dependent on the disease, her basic health, the health care facilities and personnel of the health care system. The criteria currently used to identify a near miss vary greatly. However, areas with similar health care facilities, medical records and personnel should be able to agree on suitable criteria, making their incorporation into maternal death enquiries feasible.

Aims: To perform a systematic review of screening for pre-eclampsia (PE) with the combination of uterine artery Doppler (UAD), maternal history, mean arterial pressure and/or maternal serum markers. Methods: We identified eligible studies through a search of Medline, and, for each included study, we assessed the risk of bias and extracted relevant data. We reported the performance of screening tests according to the target population (low- or high-risk), the trimester of screening (first and/or second) and the subset of PE screened for (early and late). Results: Several tests provided moderate or convincing prediction of early PE, but screening for late PE was poor. Although UAD is more accurate in the second trimester, we found encouraging results for first-trimester screening when it was combined with other markers. Performance of screening was consistently lower in populations with risk factors for PE in the maternal history. Conclusions: We present encouraging results for the prediction of early PE, even in the first trimester of pregnancy. The different performance of tests in screening for early vs. late PE, and of low- vs. high-risk populations, supports the concept that PE is a heterogeneous disease.

Cesarean rates have been rising in the United States. Recently, there has been an upsurge of interest in “cesarean on maternal request” in the absence of any medical indication, a phenomenon that will further increase the cesarean rate. This trend may not be benign on a population basis, and reliable data are lacking. This article reviews reasons for the increasing cesarean rate, describes maternal and neonatal consequences likely to accrue with a policy of cesarean on demand, and explores larger implications for public health. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to state that there continues to be a rise in the cesarean delivery rate in the United States and summarize that cesarean delivery on maternal request (CDMR) is contributing to this rise without data to indicate a decrease in maternal and fetal mortality and morbidity, possibly with a large population cost.

Depression is very common during pregnancy and the postpartum period. At this time, there is insufficient evidence to support a firm recommendation for universal antepartum or postpartum screening. There are also insufficient data to recommend how often screening should be done. There are multiple depression screening tools available for use.

We compared obstetric outcomes based on gestational weight gain in normalweight and obese women using traditional Institute of Medicine (IOM) guidelines and newly recommended Cedergren criteria. Using the New Jersey Pregnancy Risk Assessment Monitoring System (PRAMS) database and electronic birth records, perinatal outcomes were analyzed to estimate the independent effects of prepregnancy body mass index (BMI) and gestational weight gain by IOM versus Cedergren criteria. Of 9125 subjects in PRAMS database from 2002 to 2006, 53.7% had normal BMI, 12.3% were overweight, 18.2% were obese, and the rest were underweight. Among normal-weight mothers, when compared with the IOM guidelines, macrosomia (6.45% versus 4.27%) and cesarean delivery rates (30.42% versus 29.83%) were lower using Cedergren criteria but the rates of preterm delivery (5.06% versus 9.44%), low birth weight (0.38% versus 2.42%), and neonatal intensive care unit (NICU) admissions (7.02% versus 10.86%) were higher with the Cedergren criteria. Similarly, among obese patients, when compared with IOM guidelines, macrosomia (10.79% versus 5.47%) and cesarean delivery rates (43.95% versus 40.71%) were lower using Cedergren criteria but the rates of preterm delivery (6.83% versus 8.32%), low birth weight (0.87% versus 1.88%), and NICU admissions (8.92% versus 13.78%) were higher with the Cedergren criteria. Based on our results, ideal gestational weight gain is presumably somewhere between the IOM and Cedergren’s guidelines.

Over the past 25 years, 43 peripartum hysterectomies were performed at the authors' institution, an incidence of 0.64/1,000 deliveries; 31 procedures followed caesarean section and 12 were performed for haemorrhage following vaginal delivery. The common indications for hysterectomy were abnormal placentation (39.5%), uterine atony (23.3%), uterine rupture (23.3%), and haemorrhage during caesarean section (11.6%). The risk factors for hysterectomy included advancing maternal age and parity, previous caesarean section scars and abnormal placentation. Subtotal hysterectomy was performed in 72.1% cases which appeared a quicker and safer procedure than total hysterectomy in desperately ill patients. Five (11.6%) maternal deaths occurred in the series. Mortality was associated with massive haemorrhage. With rising caesarean section rates worldwide, MRI and colour Doppler sonography is useful to diagnose antepartum placenta accreta/bladder involvement in order to plan elective surgery that is associated with reduced maternal morbidity and mortality. Early decision to perform an emergency hysterectomy is essential before the patient's condition deteriorates, besides availability of an experienced obstetrician to undertake a technically demanding operation.

Objective To assess the most commonly employed diagnostic indicators of severe maternal morbidity (obstetric near-miss). Methods Review of the literature from January 1989 to August 2008. Results Fifty-one manuscripts met the eligibility criteria, and 96 indicators were utilized at least once. Admission to intensive care unit (n = 28 studies) was the indicator most frequently utilized, followed by eclampsia and hemorrhage (n = 27), blood transfusion (n = 26) and emergent hysterectomy (n = 24). Conclusion Considering these Wndings, a trial version of a 13-item instrument for diagnosing obstetric near-miss is proposed. It includes the indicators eclampsia, severe hypertension, pulmonary edema, cardiac arrest, obstetrical hemorrhage, uterine rupture, admission to intensive care unit, emergent hysterectomy, blood transfusion, anesthetic accidents, urea >15 mmol/l or creatinine >400 mmol/l, oliguria (<400 ml/24 h) and coma. Further studies should focus on consensual deWnitions for these indicators and evaluate the psychometric proprieties of this trial version.

We utilised linked birth, hospital and death data for the entire population to determine the incidence of amniotic fluid embolism (AFE) and its mortality and morbidity. AFE diagnoses were identified from International Classification of Diseases, 10th Revision (ICD10)-coded hospital and/or death records with additional case definition criteria imposed. The AFE incidence was 3.3 per 100 000 (95% CI, 1.9–4.7), maternal fatality rate 35% (95% CI, 15–59) and perinatal mortality rate 32% (95% CI, 12–56). Newly identified risk factors included induction with vaginal prostaglandin and manual removal of the placenta, and survivors were at increased risk of cerebral infarction. Although two-thirds of women and infants survived, AFE also caused severe morbidity. BJOG 2010;
DOI: 10.1111/j.1471-0528.2010.02656.x.

Cerebral aneurysmal complications rarely occur during pregnancy. Telling the difference between eclampsia and cerebral hemorrhage due to aneurysmal rupture can prove to be difficult. Aneurysmal management should be performed in an emergency but fetal prognosis should be considered. We report a series of eight pregnant women presenting aneurysmal complications and we have assessed their management and outcome. Both maternal and perinatal mortality rates were correlated with the maternal clinical score. We stress the role of combined care by both neurosurgeons and obstetricians. An emergency cesarean section followed by aneurysmal treatment appears to be a widely accepted strategy in pregnant women with cerebral aneurysmal complications.

A retrospective case-review of 52 mothers who had a peripartum hysterectomy over the past 27 years was conducted at the Rotunda hospital, Dublin, Ireland. The chief indications were uncontrollable haemorrhage due to rupture of the uterus, placenta praevia and uterine atony. Obstetric hysterectomy is a formidable operation, usually performed as a life-saving measure and requires expert surgical dexterity in order to minimise the significant morbidity. The benefits of the subtotal operation appear to be superior to those of total hysterectomy. Counselling patients having a caesarean section regarding the possibility of hysterectomy is advisable in those who have had previous uterine surgery, multiple caesarean sections or placenta praevia.

Severe preeclampsia that develops at 34 weeks of gestation is associated with high perinatal mortality and morbidity rates. Management with immediate delivery leads to high neonatal mortality and morbidity rates and prolonged hospitalization in the neonatal intensive care unit because of prematurity. Conversely, attempts to prolong pregnancy with expectant management may result in fetal death or asphyxial damage in utero and increased maternal morbidity. Since 1990, 2 randomized trials and several observational studies have evaluated the benefits vs risks of expectant management of severe preeclampsia at <34 weeks of gestation. These studies included 1677 women with gestational age between 24and 34 weeks and 115 women with gestational age of <25 weeks (overlap in some studies). The results of these studies suggest that expectant treatment in a select group of women with severe preeclampsia between 24 0/7 and 32 6/7 weeks of gestation in a suitable hospital is safe and improves neonatal outcome. For gestational age of <24 0/7 weeks, expectant treatment was associated with high maternal morbidity with limited perinatal benefit. Based on the review of these studies and our own experience, recommendations are made for the selection of the appropriate candidates for expectant treatment, criteria for maternal-fetal monitoring, and targets for delivery. Finally, we provide information regarding maternal counseling based on maternal condition and fetal gestational age at time of diagnosis.

Between January 1975 and June 1989, 240 patients with cerebral vascular malformations were treated at Henry Ford Hospital . In 16 of the patients, the treatment was influenced by pregnancy. Eleven of the patients presented with hemorrhage, four with seizures, and one with hydrocephalus. There were no maternal or fetal deaths in thepatients presenting with seizure or hydrocephalus. There were two maternal deaths and one fetal death among the cases presenting with hemorrhage . In the patients with seizure or hydrocephalus, the pregnancy was brought to term and obstetric indications used to determine the time and method of delivery . Hydrocephalus was treated by shunting, and seizures with medication . Antiepileptic drug levels fluctuate in pregnancy and hence were closely monitored to ensure therapeutic levels . Vascular malformations are the most common cause of subarachnoid hemorrhage in pregnancy . The risk of rebleed in the same pregnancy is about 27% . If an arteriovenous malformation ruptures during pregnancy and the patient's condition deteriorates, appropriate emergency surgery should be done. In stable patients, our policy has been to bring the pregnancy to term and then electively perform a craniotomy to excise the arteriovenous malformation.

Aim: To determine the prevalence of severe acute maternal morbidity (SAMM) worldwide (near miss). Method: Systematic review of all available data. The methodology followed a pre-defined protocol, an extensive search strategy of 10 electronic databases as well as other sources. Articles were evaluated according to specified inclusion criteria. Data were extracted using data extraction instrument which collects additional information on the quality of reporting including definitions and identification of cases. Data were entered into a specially constructed database and tabulated using SAS statistical management and analysis software. Results: A total of 30 studies are included in the systematic review. Designs are mainly crosssectional and 24 were conducted in hospital settings, mostly teaching hospitals. Fourteen studies report on a defined SAMM condition while the remainder use a response to an event such as admission to intensive care unit as a proxy for SAMM. Criteria for identification of cases vary widely across studies. Prevalences vary between 0.80% – 8.23% in studies that use disease-specific criteria while the range is 0.38% – 1.09% in the group that use organ-system based criteria and included unselected group of women. Rates are within the range of 0.01% and 2.99% in studies using management-based criteria. It is not possible to pool data together to provide summary estimates or comparisons between different settings due to variations in case-identification criteria. Nevertheless, there seems to be an inverse trend in prevalence with development status of a country. Conclusion: There is a clear need to set uniform criteria to classify patients as SAMM. This standardisation could be made for similar settings separately. An organ-system dysfunction/failure approach is the most epidemiologically sound as it is least open to bias, and thus could permit developing summary estimates.

OBJECTIVES: We determined the natural course of urinary protein excretion during conservative management of severe preeclampsia and investigated whether changes in urinary protein excretion can predict maternal or perinatal outcome. STUDY DESIGN: We reviewed the medical charts of 66 women with severe preeclampsia which was managed conservatively before 32 weeks of gestation and who had at least two 24-hour urinary protein determinations 4 or more days apart after admission. RESULTS: Fifty-nine (89%) of 66 women had an increase in proteinuria during conservative management of severe preeclampsia. The median increase in protein excretion after admission was 660 mg/24 hours (range -4580 to 18,960 mg/24 hours). Patients were divided into two groups. The first group (n = 24) had an increase in 24-hour urinary protein excretion of _>2 gm; the second group (n = 42) had a 24-hour urinary protein excretion that decreased (n = 7) or increased by <2 gm (n = 35). There were no cases of eclampsia or stillbirth in either group. The rate of HELLP (hemolysis, elevated liver enzyme levels, low platelet counts) syndrome, abruptio placentae, cesarean delivery because of fetal distress, 5-minute Apgar scores <6, and the admission-to-delivery intervals were all similar in the two groups. CONCLUSIONS: Proteinuria increases in most women with severe preeclampsia managed conservatively. No differences in maternal or fetal outcomes were found between pregnancies with marked increases in proteinuria and those with modest or no increases.

Amniotic fluid embolism (AFE) is a rare obstetric catastrophe that occurs suddenly and without warning. AFE is a condition that is poorly understood and often difficult to diagnose, but has a high maternal and neonatal morbidity and mortality. Since it was first described in 1926, the underlying pathophysiology has eluded researchers and clinicians. While a new understanding of the syndrome has emerged with the advent of a national registry in the 1980s, recommendations for diagnostic methods and treatment in the acute phase of the event remain unclear.The purpose of this article is to provide the reader with a historical look at the phenomenon of AFE, a description of its suspected pathophysiology, and recommendations for nursing interventions. A review of data from the national registry and other classic studies are included.

A 35-year-old woman who has never been pregnant and who has a 5-year history of hypertension wants to become pregnant. She has stopped using contraception. Her only medication is lisinopril at a dose of 10 mg per day. Her blood pressure is 124/68 mm Hg, and her body-mass index (the weight in kilograms divided by the square of the height in meters) is 27. What would you advise?

Background and Purpose: The incidence, causes, and prognosis of nonhemorrhagic strokes and intraparenchymal hemorrhages occurring in association with pregnancy or puerperium are poorly understood. Methods: We carried out a retrospective (1989 through 1991) and prospective (1992) study in 63 public maternities (348 295 deliveries) of the region of Ile de France (10 660 554 inhabitants) and in the neurology, neurosurgery, and intensive care units of the same geographic area. Records of women who suffered a cerebrovascular event during pregnancy or the first 2 weeks postpartum were reviewed by two study neurologists. Stroke was defined according to the criteria of the World Health Organization. Results: Thirty-one cases of strokes were identified, including 15 nonhemorrhagic strokes (including strokelike deficits associated with eclampsia) and 16 intraparenchymal hemorrhages, assessed in all cases by CT scan and/or MRI. The incidence of nonhemorrhagic strokes in women who delivered in public maternities of Ile de France was 4.3 per 100 000 deliveries (95% confidence interval, 2.4 to 7.1) and that of intraparenchymal hemorrhage was 4.6 per 100 000 deliveries (95% confidence interval, 2.6 to 7.5). Eclampsia accounted for 47% of cases of nonhemorrhagic strokes. The other causes were extracranial vertebral artery dissection, postpartum cerebral angiopathy, inherited protein S deficiency, and disseminated intravascular coagulation associated with amniotic fluid embolism. The cause remained undetermined in four cases despite extensive investigations. Eclampsia accounted for 44% of intraparenchymal hemorrhages. Another 37% were due to rupture of a vascular malformation. The cause remained undetermined in three cases. There were four maternal deaths (all associated with intraparenchymal hemorrhage), three of them in eclamptic women. Fetal mortality and prematurity were associated with eclampsia. Conclusions: The incidence of nonhemorrhagic stroke does not seem to be much increased during pregnancy and early puerperium. In contrast to that in the nonpregnant state, the frequency of intraparenchymal hemorrhage in pregnancy appears to be similar to that of nonhemorrhagic strokes, suggesting that pregnancy may increase the risk of cerebral hemorrhage. Eclampsia is the main cause of both nonhemorrhagic stroke and intraparenchymal hemorrhage. Intraparenchymal hemorrhage associated with eclampsia carries a poor prognosis.

We assessed the impact of a lifestyle modification program (LMP) on weight gain in pregnancy and evaluated its effect on adverse pregnancy outcomes. A prospective matched controlled study design was employed. Inclusion criteria consisted of pregnant women with singleton gestations and body mass index (BMI) >30 without underlying medical conditions. In the study group, patients were prospectively enrolled in the first trimester. Through the LMP, women participated in a comprehensive program on nutrition, exercise, and weight control in pregnancy. The control group consisted of matched patients by starting BMI, parity, and socioeconomic status during the same study period cared for at the same institution. The primary outcome evaluated was weight gain in pregnancy. Adverse pregnancy outcomes including preeclampsia, gestational diabetes, gestational hypertension, and various postpartum complications were evaluated between the two groups. Statistical analysis was performed using nonparametric methods, with p<0.5 considered significant. Twenty-eight patients were recruited for this study and underwent the intervention. Patient compliance with the LMP was 75%, two patients were lost to follow-up, one had a preterm delivery, and four had incomplete data due to various reasons. Twenty-one patients completed their pregnancy and were available for analysis. Twenty matched control patients were identified for analysis. Study participants gained significantly less weight in their pregnancies when compared with controls (mean weight gain 17 versus 34 pounds, respectively; p¼0.008). Secondary outcomes of preeclampsia, gestational diabetes, cesarean section, as well as infant birth weight did not significantly differ between the groups. This study suggests an effective method of reducing prenatal weight gain in the obese population. This type of comprehensive intervention could be an important, cost-effective risk-reduction strategy.

There are several obstetric, medical, and surgical disorders that share many of the clinical and laboratory findings of patients with severe preeclampsia–hemolysis, elevated liver enzymes, and low platelets syndrome. Imitators of severe preeclampsia–hemolysis, elevated liver enzymes, and low platelets syndrome are life-threatening emergencies that can develop during pregnancy or in the postpartum period. These conditions are associated with high maternal mortality, and survivors may face long-term sequelae. Perinatal mortality and morbidity also remain high in many of these conditions. The pathophysiologic abnormalities in many of these disorders include thrombotic microangiopathy, thrombocytopenia, and hemolytic anemia. Some of these disorders include acute fatty liver of pregnancy, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, and acute exacerbation of systemic lupus erythematosus. Because of the rarity of these conditions during pregnancy and postpartum, the available literature includes only case reports and case series describing these syndromes. Consequently, there are no systematic reviews or randomized trials on these subjects. Differential diagnosis may be difficult due to the overlap of several clinical and laboratory findings of these syndromes. It is important that the clinician make the accurate diagnosis when possible because the management and complications from these syndromes may be different. For example, severe preeclampsia and acute fatty liver of pregnancy are treated by delivery, whereas it is possible to continue pregnancy in those with thrombotic thrombocytopenic purpura–hemolytic uremic syndrome and exacerbation of systemic lupus erythematosus. This review focuses on diagnosis, management, and counseling of women who develop these syndromes based on results of recent studies.

Gestational hypertension and preeclampsia are common disorders during pregnancy, with the majority of cases developing at or near term. The development of mild hypertension or preeclampsia at or near term is associated with minimal maternal and neonatal morbidities. In contrast,the onset of severe gestational hypertension and/or severe preeclampsia before 35 weeks’ gestation is associated with significant maternal and perinatal complications. Women with diagnosed gestational hypertension–preeclampsia require close evaluation of maternal and fetal conditions for the duration of pregnancy, and those with severe disease should be managed in-hospital. The decision between delivery and expectant management depends on fetal gestational age, fetal status, and severity of maternal condition at time of evaluation. Expectant management is possible in a select group of women with severe preeclampsia before 32 weeks’ gestation. Steroids are effective in reducing neonatal mortality and morbidity when administered to those with severe disease between 24 and 34 weeks’ gestation. Magnesium sulfate should be used during labor and for at least 24 hours postpartum to prevent seizures in all women with severe disease. There is an urgent need to conduct randomized trials to determine the efficacy and safety of antihypertensive drugs in women with mild hypertension–preeclampsia. There is also a need to conduct a randomized trial to determine the benefits and risks of magnesium sulfate during labor and postpartum in women with mild preeclampsia.

Gestational hypertension/pre-eclampsia is the most frequent obstetrical complication, complicating 26%-29% of all gestations in nulliparous women. In general, the diagnosis of mild gestational hypertension/pre-eclampsia is made at 38 weeks or more in approximately 80% of cases. For many years, the optimal timing of delivery for patients with mild gestational hypertension/pre-eclampsia at 37-0/7 to 39-6/7 weeks was unclear. Recently, investigators of the HYPITAT (Pregnancy-induced hypertension and pre-eclampsia after 36 weeks: induction of labor versus expectant monitoring: A comparison of maternal and neonatal outcome, maternal quality of life and costs) randomized trial evaluated maternal and neonatal complications in patients at 36-40 weeks’ gestation who were randomized to either induction of labor or expectant monitoring. The results of this trial revealed that induction of labor at or after 37-0 weeks was associated with lower rate of maternal complications without increased rates of either cesarean delivery or neonatal complications. In contrast, the optimum management for those with mild hypertension/pre-eclampsia with stable maternal and fetal conditions at 34-0/7 to 36-6/7 weeks remains uncertain. Therefore, there is urgent need for research to evaluate the reasons for late preterm birth in such women as well as for a randomized trial to evaluate the optimal timing for delivery in such patients.

Postpartum hypertension can be related to persistence of gestational hypertension, preeclampsia, or preexisting chronic hypertension, or it could develop de novo postpartum secondary to other causes. There are limited data describing the etiology, differential diagnosis, and management of postpartum hypertension-preeclampsia. The differential diagnosis is extensive, and varies from benign (mild gestational or essential hypertension) to life-threatening such as severe preeclampsia-eclampsia, pheochromocytoma, and cerebrovascular accidents. Therefore, medical providers caring for postpartum women should be educated about continued monitoring of signs and symptoms and prompt management of these women in a timely fashion. Evaluation and management should be performed in a stepwise fashion and may require a multidisciplinary approach that considers predelivery risk factors, time of onset, associated signs/symptoms, and results of selective laboratory and imaging findings. The objective of this review is to increase awareness and to provide a stepwise approach toward the diagnosis and management of women with persistent and/or new-onset hypertension-preeclampsia postpartum period.

Severe preeclampsia that develops at "34 weeks of gestation is associated with high perinatal mortality and morbidity rates. Management with immediate delivery leads to high neonatal mortality and morbidity rates and prolonged hospitalization in the neonatal intensive care unit because of prematurity. Conversely, attempts to prolong pregnancy with expectant management may result in fetal death or asphyxial damage in utero and increased maternal morbidity. Since 1990, 2 randomized trials and several observational studies have evaluated the benefits vs risks of expectant management of severe preeclampsia at "34 weeks of gestation. These studies included 1677 women with gestational age between 24 and 34 weeks and 115 women with gestational age of "25 weeks (overlap in some studies). The results of these studies suggest that expectant treatment in a select group of women with severe preeclampsia between 24 0/7 and 32 6/7 weeks of gestation in a suitable hospital is safe and improves neonatal outcome. For gestational age of "24 0/7 weeks, expectant treatment was associated with high maternal morbidity with limited perinatal benefit. Based on the review of these studies and our own experience, recommendations are made for the selection of the appropriate candidates for expectant treatment, criteria for maternal-fetal monitoring, and targets for delivery. Finally, we provide information regarding maternal counseling based on maternal condition and fetal gestational age at time of diagnosis.

Preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelets syndrome are major obstetric disorders that are associated with substantial maternal and perinatal morbidities. As a result, it is important that clinicians make timely and accurate diagnoses to prevent adverse maternal and perinatal outcomes associated with these syndromes. In general, most women will have a classic presentation of preeclampsia (hypertension and proteinuria) at >20 weeks of gestation and/or <48 hours after delivery. However, recent studies have suggested that some women will experience preeclampsia without >/=1 of these classic findings and/or outside of these time periods. Atypical cases are those that develop at <20 weeks of gestation and >48 hours after delivery and that have some of the signs and symptoms of preeclampsia without the usual hypertension or proteinuria. The purpose of this review was to increase awareness of the nonclassic and atypical features of preeclampsia-eclampsia. In addition, a stepwise approach toward diagnosis and treatment of patients with these atypical features is described.

OBJECTIVE: Although repeat cesarean deliveries often are associated with serious morbidity, they account for only a portion of abdominal deliveries and are overlooked when evaluating morbidity. Our objective was to estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries.
METHODS: Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999-2002).
RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively.
CONCLUSION: Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.
LEVEL OF EVIDENCE: II-2.

Objective To develop an indicator of maternal near miss as a proxy for maternal death and to study its association with maternal factors and perinatal outcomes. Methods In a multicenter cross-sectional study, we collected maternal and perinatal data from the hospital records of a sample of women admitted for delivery over a period of two to three months in 120 hospitals located in eight Latin American countries. We followed a stratified multistage cluster random design. We assessed the intra-hospital occurrence of severe maternal morbidity and the latter’s association with maternal characteristics and perinatal outcomes. Findings Of the 97 095 women studied, 2964 (34 per 1000) were at higher risk of dying in association with one or more of the following: being admitted to the intensive care unit (ICU), undergoing a hysterectomy, receiving a blood transfusion, suffering a cardiac or renal complication, or having eclampsia. Being older than 35 years, not having a partner, being a primipara or para > 3, and having had a Caesarean section in the previous pregnancy were factors independently associated with the occurrence of severe maternal morbidity. They were also positively associated with an increased occurrence of low and very low birth weight, stillbirth, early neonatal death, admission to the neonatal ICU, a prolonged maternal postpartum hospital stay and Caesarean section. Conclusion Women who survive the serious conditions described could be pragmatically considered cases of maternal near miss. Interventions to reduce maternal and perinatal mortality should target women in these high-risk categories.

Abstract Posterior reversible encephalopathy syndrome (PRES) is characterized by headache, altered mental status, visual disturbances, and seizures. Radiological features typically include edema of the posterior cerebral regions, especially of the parietooccipital lobes. Atypical imaging features, such as involvement of anterior cerebral regions, deep white matter, and the brain stem are also frequently seen. Vasoconstriction is common in vascular imaging. Different conditions have been associated with PRES, but toxemia of pregnancy, solid organ or bone marrow transplantation, immunosuppressive treatment, cancer chemotherapy, autoimmune diseases, and hypertension are most commonly described. The pathophysiology of PRES is unclear and different hypotheses are being discussed. Posterior reversible encephalopathy syndrome is best managed by monitoring and treatment in the setting of a neurointensive care unit. The prognosis is usually benign with complete reversal of clinical symptoms within several days, when adequate treatment is immediately initiated. Treatment of severe hypertension, seizures, and withdrawal of causative agents represent the hallmarks of specific therapy in PRES. Delay in diagnosis and treatment may lead to permanent neurological sequelae. Therefore, awareness of PRES is of crucial importance for the intensivist.

Abstract Posterior reversible encephalopathy syndrome (PRES) is characterized by headache, altered mental status, visual disturbances, and seizures. Radiological features typically include edema of the posterior cerebral regions, especially of the parietooccipital lobes. Atypical imaging features, such as involvement of anterior cerebral regions, deep white matter, and the brain stem are also frequently seen. Vasoconstriction is common in vascular imaging. Different conditions have been associated with PRES, but toxemia of pregnancy, solid organ or bone marrow transplantation, immunosuppressive treatment, cancer chemotherapy, autoimmune diseases, and hypertension are most commonly described. The pathophysiology of PRES is unclear and different hypotheses are being discussed. Posterior reversible encephalopathy syndrome is best managed by monitoring and treatment in the setting of a neurointensive care unit. The prognosis is usually benign with complete reversal of clinical symptoms within several days, when adequate treatment is immediately initiated. Treatment of severe hypertension, seizures, and withdrawal of causative agents represent the hallmarks of specific therapy in PRES. Delay in diagnosis and treatment may lead to permanent neurological sequelae. Therefore, awareness of PRES is of crucial importance for the intensivist.

Perimortem caesarean section is very rare, mostly resulting in high mortality of mother and/or fetus. We report a case of successful resuscitation of both mother and newborn following maternal cardiac arrest prior to delivery. Postoperative outcome was complicated by severe bleeding and coagulopathy following fibrinolysis and subcapsular hepatic haematoma. We consider a fast reaction time based on a special in-hospital emergency team for immediate caesarean section and an aggressive management of coagulopathy as major factors that led to both patients recovery without neurological sequelae.

Aneurysmal subarachnoid hemorrhage during pregnancy is rare but is an important cause of maternal mortality. Physiologic changes in pregnancy may predispose to aneurysm formation and rupture. In general, neurosurgical considerations take precedence over obstetric considerations. Ruptured aneurysms should be treated as they would be in patients who are not pregnant. Unruptured aneurysms should be treated if they are symptomatic or enlarging. Other aneurysms should be treated on an individual basis.

OBJECTIVE: We sought to determine whether genetic variants associated with diabetes and obesity predict gestational weight gain. STUDY DESIGN: A total of 960 participants in the Pregnancy, Infection, and Nutrition cohorts were genotyped for 27 single-nucleotide polymorphisms (SNPs) associated with diabetes and obesity. RESULTS: Among Caucasian and African American women (n = 960), KCNQ1 risk allele carriage was directly associated with weight gain (P < .01). In Bayesian hierarchical models among Caucasian women (n = 628), we found posterior odds ratios >3 for inclusion of TCF2 and THADA SNPs in our models. Among African American women (n = 332), we found associations between risk allele carriage and weight gain for the THADA and INSIG2 SNPs. In Bayesian variable selection models, we found an interaction between the TSPAN8 risk allele and pregravid obesity, with lower weight gain among obese risk allele carriers. CONCLUSION: We found evidence that diabetes and obesity risk alleles interact with maternal pregravid body mass index to predict gestational weight gain.

Amniotic fluid embolism occurs rarely but is a leading cause of maternal mortality. A high index of clinical suspicion is necessary to make an early diagnosis to reduce morbidity and mortality. We report a non-fatal case of amniotic fluid embolism occurring during a caesarean section, with special emphasis on the mode of development and diagnosis. The initial presentation of this syndrome was a coagulopathy, followed by the usual complications of massive bleeding. Although non-specific, the diagnosis of amniotic fluid embolism was supported by the observation of amniotic fluid in the central venous blood as well as in the broncho-alveolar fluid.

Optimal maternal and neonatal health requires the expertise of maternity-care providers who base their decisions on solid research. Optimal care, however, also requires active patient participation, which is best accomplished through advocacy organisations that represent the perspective of diverse patient populations. Patients who come together under the auspices of a patient advocacy organisation, sometimes called consumer groups, can have a unique and powerful voice to advance the goals (or overcome the inertia) of the healthcare system. For preeclampsia, a condition that still carries the burden of no cure and seriously adverse or deadly outcomes, all three components - care providers, researchers and patients - are required to realise progress. In this chapter, we briefly describe the effect of preeclampsia on women, discuss the role of patient advocacy organisations, and propose a six-point call to action that can serve as a compass for patients to collaborate with practitioners, investigators, funders, non-governmental organisations, and policy makers on a set of articulated and comprehensive goals.

Guideline Objective(s) To standardize the management approach of severe pre-eclampsia and eclampsia in the immediate pre- and postdelivery period in order to improve patient and newborn outcome

Objectives: To evaluate the effect of prolonged administration of high-dose prednisolone on early onset HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome during expectant management. Study design: A randomized, double-blind trial was performed in 31 pregnant women with HELLP syndrome with an onset before 30 weeks gestation. Patients received either 50 mg prednisolone or placebo intravenously twice a day. Primary outcome measures were the entry-to-delivery interval and the number of recurrent HELLP exacerbations in the antepartum period. Results: Serious maternal morbidity was considerable, in particular in the placebo group where even on maternal occurred as a consequence of liver rupture. The mean entry-delivery interval did not differ between the prednisolone group (6.9 days) and the placebo group (8.0 days). However, patients in the prednisolone group had a significant lower risk of a recurrent HELLP exacerbation after the initial crisis had subsided, as compared to patients in the placebo group (HR 0.3, with 95% CI 0.3–0.9). Platelet count recovered faster in the prednisolone group as compared to the placebo group (mean 1.7 days versus 6.2 days, P < 0.01). Conclusions: HELLP syndrome remote from term causes high risk for serious maternal morbidity and mortality. When expectant management is pursued in selected patients with a HELLP syndrome remote from term, prolonged administration of prednisolone reduces the risk of recurrent HELLP syndrome exacerbations.

Background: Timing of delivery is difficult to judge in preeclampsia. Objective: To compare the differences of maternal and perinatal outcome of patients with severe preeclampsia and essential hypertension with superimposed preeclampsia, with expectant management at 24-34 weeks'gestation. Study design: A retrospective review of a conservative regime using intravenous magensium sulfate, glucocorticoids and antihypertensive drugs, monitored by serial liver function tests, full blood count, coagulation profile, and renal function tests. Fetal status was assessed by daily non-stress test and ultrasound twice by week. Results: A total number of 100 women had severe preeclampsia and 29 superimposed preeclampsia. The average pregnancy prolongation was 8.4 and 8.5 days, respectively. Oliguria, abruption placentae and HELLP syndrome were frequent complications similar in each group. There were no cases of eclampsia or disseminated coagulopathy in either group. The total neonatal survival rate was 93% in both groups. Conclusion: Expectant management is equally safe in both superimposed preeclampsia and severe preeclampsia of early onset.

Objective: To assess the prevalence, clinical presentations, and neuroimaging abnormalities in a series of patients treated for eclampsia at Mayo Clinic in Rochester, MN. Patients and Methods: We reviewed the records of all pregnant patients diagnosed as having eclampsia at Mayo Clinic in Rochester, MN, between January 1, 2001, and December 31, 2008. All patients who underwent neuroimaging were identified, and all studies were reviewed by an independent neuroradiologist. Comparisons were made between groups who did and did not undergo imaging to identify differentiating clinical or laboratory variables. Results: Thirteen cases of eclampsia were found, with neuroimaging studies available for 7: magnetic resonance imaging (n=6) and computed tomography (n=1). All 7 patients developed eclamptic seizures, and 2 of 7 patients had severe hypertension, with recorded systolic blood pressures exceeding 180 mm Hg. Neuroimaging showed characteristic changes of posterior reversible encephalopathy syndrome (PRES) in all patients. Follow-up imaging showed resolution in 2 of 3 patients; 1 patient had residual neuroimaging abnormalities. Conclusion: Our results suggest that the clinical syndrome of eclampsia is associated with an anatomical substrate that is recognizable by neuroimaging as PRES. The levels of blood pressure elevation are lower than those reported in cases of PRES because of hypertensive encephalopathy. Further studies are needed to determine whether more aggressive blood pressure control and early neuroimaging may have a role in the management of these patients.

Maternal deaths in developed countries continue to decline and are rare. Maternal mortality statistics are essentially similar in the United States and United Kingdom. However, the situation is completely different in developing countries, where maternal mortality exceeds 0.5 million every year. This article not only assesses morbidity risks in some of the leading causes of maternal death but also highlights strategies to minimize the risks and to prevent maternal morbidity and mortality.

OBJECTIVE: To estimate the incidence and predictors of severe obstetric morbidity.
DESIGN: Development of definitions of severe obstetric morbidity by literature review. Case-control study from a defined delivery population with four randomly selected pregnant women as controls for every case.
SETTING: All 19 maternity units within the South East Thames region and six neighbouring hospitals caring for pregnant women from the region between 1 March 1997 and 28 February 1998.
PARTICIPANTS: 48 865 women who delivered during the time frame.
RESULTS: There were 588 cases of severe obstetric morbidity giving an incidence of 12.0/1000 deliveries (95% confidence interval 11.2 to 13.2). During the study there were five maternal deaths attributed to conditions studied. Disease specific morbidities per 1000 deliveries were 6.7 (6.0 to 7.5) for severe haemorrhage, 3.9 (3.3 to 4.5) for severe pre-eclampsia, 0.2 (0.1 to 0.4) for eclampsia, 0.5 (0.3 to 0.8) for HELLP (Haemolysis, Elevated Liver enzymes, and Low Platelets) syndrome, 0.4 (0.2 to 0.6) for severe sepsis, and 0.2 (0.1 to 0.4) for uterine rupture. Age over 34 years, non-white ethnic group, past or current hypertension, previous postpartum haemorrhage, delivery by emergency caesarean section, antenatal admission to hospital, multiple pregnancy, social exclusion, and taking iron or anti-depressants at antenatal booking were all independently associated with morbidity after adjustment.
CONCLUSION: Severe obstetric morbidity and its relation to mortality may be more sensitive measures of pregnancy outcome than mortality alone. Most events are related to obstetric haemorrhage and severe pre-eclampsia. Caesarean section quadruples the risk of morbidity. Development and evaluation of ways of predicting and reducing risk are required with particular emphasis paid on the management of haemorrhage and pre-eclampsia.

Objective To identify the impact of pregnancy and childbirth, and severe obstetric morbidity on outcome 6 to 12 months postpartum. Design Questionnaire assessment of postnatal outcome in a cohort study. Setting South East Thames, UK. Population All women resident in South East Thames and delivering between 1st March 1997 and 28th February 1998. Methods Questionnaire study of a cohort of women who experienced a severe obstetric morbidity during pregnancy or labour (cases), compared with a cohort of women who did not (controls). Main outcome measures Assessment of postnatal depression risk [Edinburgh Postnatal Depression Scale (EPDS)], general health [Short Form 36 (SF-36)], sexual activity and use of health services between 6 and 12 months postpartum. Results There were 331 cases and 1339 controls out of 48,262 deliveries. Six to 12 months after delivery, 77 (23.3%) of cases and 272 (20.5%) of the controls were at risk of postnatal depression (P ¼ 0.25; 95% CI for difference 2.2% to 7.9%), 43.1% of cases were having problems with sexual relations compared with 18.7% of controls (P < 0.001; 95% CI for difference 8.9% to 21.9%). There was evidence of poorer general health in cases. Some 31.5% of cases attended outpatients in the first six months and 9.4% required emergency admission to hospital compared with 17.0% (P < 0.001; 95% CI for difference 9.1% to 19.9%) and 3.7% (P < 0.001; 95% CI for difference 2.4% to 9.0%), respectively, in controls. Conclusion Both control pregnancy and childbirth and severe obstetric morbidity are associated with significant postnatal morbidity. A severe obstetric morbid event significantly influences women’s sexual health and wellbeing and increases health services utilisation. Prevention and appropriate management of severe obstetric morbid events may reduce these outcomes.

Objective. Several studies have shown an increased risk for neural tube defects associated with prepregnancy maternal obesity. Because few recent studies have examined the relation between maternal prepregnancy obesity and overweight and other birth defects, we explored the relation for several birth defects and compared our findings with those of previous studies. Methods. We conducted a population-based case-control study of several selected major birth defects using data from the Atlanta Birth Defects Risk Factor Surveillance Study. Mothers who delivered an infant with and without selected birth defects in a 5-county metropolitan Atlanta area between January 1993 and August 1997 were interviewed. Maternal body mass index (BMI) was calculated from self-reported maternal prepregnancy weight and height. Women with known preexisting diabetes were excluded. The risks for obese women (BMI >30) and overweight women (BMI 25.0 –29.9) were compared with those for average-weight women (BMI 18.5– 24.9). Results. Obese women were more likely than average-weight women to have an infant with spina bifida (unadjusted odds ratio [OR]: 3.5; 95% confidence interval [CI]: 1.2–10.3), omphalocele (
OR: 3.3; 95%
CI: 1.0 –10.3), heart defects (
OR: 2.0; 95%
CI: 1.2–3.4), and multiple anomalies (
OR: 2.0; 95%
CI: 1.0 –3.8). Overweight women were more likely than average-weight women to have infants with heart defects (
OR: 2.0; 95%
CI: 1.2–3.1) and multiple anomalies (
OR: 1.9; 95%
CI: 1.1–3.4). Conclusions. Our study confirmed the previously established association between spina bifida and prepregnancy maternal obesity and found an association for omphalocele, heart defects, and multiple anomalies among infants of obese women. We also found an association between heart defects and multiple anomalies and being overweight before pregnancy. A higher risk for some birth defects is yet another adverse pregnancy outcome associated with maternal obesity. Obesity prevention efforts are needed to increase the number of women who are of healthy weight before pregnancy. Pediatrics 2003;111:1152–1158; obesity, body mass index, pregnancy, neural tube defect, congenital anomaly, birth defect.

Infants as young as 3 months are able to detect depression in their mothers. Depressed mothers are sufficiently different from nondepressed mothers in affect and interaction that the social, emotional, and cognitive functioning of their infants are compromised. This article reviews current findings on the effects of maternal depression and psychiatric illness on infants

Objective: This study was undertaken to determine whether obesity is associated with obstetric complications and cesarean delivery. Methods: Alarge prospective multicenter database was studied. Subjects were divided into 3 groups: body mass index (BMI) less than 30 (control), 30 to 34.9 (obese), and 35 or greater (morbidly obese). Groups were compared by using univariate and multivariable logistic regression analyses. Results: The study included 16,102 patients: 3,752 control, 1,473 obese, and 877 morbidly obese patients. Obesity and morbid obesity had a statistically significant association with gestational hypertension (odds ratios [ORs] 2.5 and 3.2), preeclampsia (ORs 1.6 and 3.3), gestational diabetes (ORs 2.6 and 4.0), and fetal birth weight greater than 4000 g (ORs 1.7 and 1.9) and greater than 4500 g (ORs 2.0 and 2.4). For nulliparous patients, the cesarean delivery rate was 20.7% for the control group, 33.8% for obese, and 47.4% for morbidly obese patients. Conclusion: Obesity is an independent risk factor for adverse obstetric outcome and is significantly associated with an increased cesarean delivery rate

BACKGROUND: Although death rates are often used to monitor the quality of health care, in industrialized countries maternal deaths have become rare. Severe maternal morbidity has therefore been proposed as a supplementary indicator for surveillance of the quality of maternity care. Our purpose in this study was to describe severe maternal morbidity in Canada over a 10-year period, among women with or without major pre-existing conditions.
METHODS: We carried out a retrospective cohort study of severe maternal morbidity involving 2,548,824 women who gave birth in Canadian hospitals between 1991 and 2000. Thirteen conditions that may threaten the life of the mother (e.g., eclampsia) and 11 major pre-existing chronic conditions (e.g., diabetes) that could be identified from diagnostic codes were noted.
RESULTS: The overall rate of severe maternal morbidity was 4.38 per 1000 deliveries. The fatality rate among these women was 158 times that of the entire sample. Rates of venous thromboembolism, uterine rupture, adult respiratory distress syndrome, pulmonary edema, myocardial infarction, severe postpartum hemorrhage requiring hysterectomy, and assisted ventilation increased substantially from 1991 to 2000. The presence of major pre-existing conditions increased the risk of severe maternal morbidity to 6-fold.
INTERPRETATION: Severe maternal morbidity occurs in about 1 of 250 deliveries in Canada, with marked recent increases in certain morbid conditions such as pulmonary edema, myocardial infarction, hemorrhage requiring hysterectomy, and the use of assisted ventilation.

OBJECTIVE: Most studies of peripartum hysterectomy are conducted in single institutions, limiting the ability to provide national incidence estimates and examine risk factors. The objective of this study was to provide a national estimate of the incidence of peripartum hysterectomy and to examine factors associated with the procedure.
METHODS: We used data for 1998-2003 from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, an annual nationally representative survey of inpatient hospitalizations. Peripartum hysterectomy was defined as a hysterectomy and delivery occurring during the same hospitalization. Odds ratios (ORs) and 95% confidence intervals (CIs) were adjusted for maternal and hospital characteristics using logistic regression.
RESULTS: During 1998-2003, an estimated 18,339 peripartum hysterectomies occurred in the United States (0.77 per 1,000 deliveries). Compared with vaginal delivery without a previous cesarean delivery, the ORs of peripartum hysterectomy for other delivery types were as follows: repeat cesarean, 8.90 (95% CI 8.09-9.79); primary cesarean, 6.54 (95% CI 5.95-7.18); and vaginal birth after cesarean, 2.70 (95% CI 2.23-3.26). Multiple births were associated with an increased risk compared with singleton births (OR 1.41, 95% CI 1.16-1.71).
CONCLUSION: Our results suggest that vaginal birth after cesarean, primary and repeat cesarean deliveries, and multiple births are independently associated with an increased risk for peripartum hysterectomy. These findings may be of concern, given the increasing rate of both cesarean deliveries and multiple births in the United States.
LEVEL OF EVIDENCE: III.

Preeclampsia is a leading cause of maternal and infant mortality and morbidity worldwide. Both Swedish snuff and cigarette smoke include nicotine, but combustion products accompany only smoking. The aims of this study were to compare the effects of Swedish snuff and cigarette smoking on preeclampsia risk and to estimate whether changes in tobacco habits during pregnancy affect the risk of developing term preeclampsia. We used information from the Swedish Birth Register on all singleton births in Sweden during the years 1999–2006 (n
612 712). Compared with nontobacco users, women who used snuff in early pregnancy had an adjusted odds ratio (OR) for preeclampsia of 1.11 (95%
CI: 0.97 to 1.28). The corresponding ORs for light and heavy smokers were 0.66 (95%
CI: 0.61 to 0.71) and 0.51 (95%
CI: 0.44 to 0.58), respectively, with ORs lower for term than preterm preeclampsia. Compared with nontobacco users, women who smoked in early pregnancy but had quit smoking before late pregnancy (weeks 30 to 32) had an adjusted OR for term preeclampsia of 0.94 (95%
CI: 0.83 to 1.08). The corresponding OR for women who did not use tobacco in early pregnancy but had started to smoke before late pregnancy was 0.65 (95%
CI: 0.50 to 0.85). We conclude that tobacco combustion products rather than nicotine are the probable protective ingredients against preeclampsia in cigarette smoke. Because change of smoking habits during pregnancy influence risk, we further conclude that it is the smoking habits in the middle or late rather than in the beginning of pregnancy that seem to affect the risk of preeclampsia.

OBJECTIVE: Knowledge about the causes of placental dysfunction disorders is limited. We performed an intergenerational study, focusing on the risks of placental dysfunction disorders in mothers and fathers who had been born small for gestational age (SGA). STUDY DESIGN: Using linked generational data from the Swedish Medical Birth Register from 1973-2006, we identified 321,383 mother-offspring units and 135,637 mother-father-offspring units. RESULTS: Compared with mothers who had not been born SGA, mothers who had been born SGA had the following adjusted odds ratios: late preeclampsia, 1.41 (95% confidence interval [CI], 1.26 –1.57); early preeclampsia, 1.87 (95% CI, 1.38 –2.35); placental abruption, 1.60 (95% CI, 1.23–2.09); spontaneous preterm birth, 1.11 (95% CI, 1.00–1.23); and stillbirth, 1.24 (95% CI, 0.84 –1.82). Compared with parents who had not been born SGA, the risk of preeclampsia was more than 3-fold increased if both parents had been born SGA, whereas if only the mother had been born SGA, the corresponding risk was increased by only 50%. CONCLUSION: There is an intergenerational recurrence of placental dysfunction disorders on the maternal side and most likely also on the paternal side.

Study Objective: Postpartum preeclampsia/eclampsia is the presence of hypertension and proteinuria, with or without seizures, occurring up to 4 weeks after delivery. We describe the Emergency Department (ED) presentation, signs and symptoms, results of diagnostic studies, management, and outcome in a cohort of patients diagnosed with postpartum preeclampsia/eclampsia at our institutions, and use this to review the diagnosis and management of postpartum preeclampsia/eclampsia. Methods: A retrospective chart review was conducted at two urban teaching hospitals. Twenty-two cases were identified via ICD-9 (International Classification of Diseases, 9th revision) codes of discharge diagnoses over an 8-year period. Only those patients who initially presented to an ED in the postpartum period after hospital discharge were included. A standardized data tool was used to extract demographic data, signs and symptoms of preeclampsia/eclampsia, ancillary studies previously associated with eclamptic pathology, and outcome during admission. Results: Of the 22 women, over half (55%) had not been diagnosed with preeclampsia in the ante- or peripartum period. Common prodromal symptoms and signs in the postpartum presentation included headache, visual changes, hypertension, edema, proteinuria, elevated uric acid, and elevated liver function tests. All 4 patients who seized had prodromal symptoms. Women presented from 3 to 10 days postpartum (median: 5 days). Only 10 women were primiparas. Nineteen women presented with diastolic blood pressures > 90mm, and only 3 of these had diastolic blood pressures of 110mm Hg or greater. Conclusions: Postpartum preeclampsia/eclampsia often presents to the ED without a history of preeclampsia during the pregnancy. Further, not all women with this diagnosis who present to the ED in the postpartum period will have each of the “classic” features of this disease, including elevated blood pressure, edema, proteinuria, and hyperreflexia. This report is intended to inform emergency physicians of the presentation of preeclampsia/eclampsia in the postpartum period, including symptoms of headache, vision changes, elevated blood pressure, or seizure up to 4 weeks after delivery.

This article is being published concurrently in the September 2009 issue of Obstetrics & Gynecology. Objective To address the maternal and neonatal risks of both depression and antidepressant exposure and develop algorithms for periconceptional and antenatal management. Method Representatives from the American Psychiatric Association, the American College of Obstetricians and Gynecologists and a consulting developmental pediatrician collaborated to review English language articles on fetal and neonatal outcomes associated with depression and antidepressant treatment during childbearing. Articles were obtained from Medline searches and bibliographies. Search keywords included pregnancy, pregnancy complications, pregnancy outcomes, depressive disorder, depressive disorder/dt, abnormalities/drug-induced/epidemiology, abnormalities/drug-induced/et. Iterative draft manuscripts were reviewed until consensus was achieved. Results Both depressive symptoms and antidepressant exposure are associated with fetal growth changes and shorter gestations, but the majority of studies that evaluated antidepressant risks were unable to control for the possible effects of a depressive disorder. Short-term neonatal irritability and neurobehavioral changes are also linked with maternal depression and antidepressant treatment. Several studies report fetal malformations in association with first trimester antidepressant exposure but there is no specific pattern of defects for individual medications or class of agents. The association between paroxetine and cardiac defects is more often found in studies that included all malformations rather than clinically significant malformations. Late gestational use of selective serotonin reuptake inhibitor antidepressants is associated with transitory neonatal signs and a low risk for persistent pulmonary hypertension in the newborn. Psychotherapy alone is an appropriate treatment for some pregnant women; however, others prefer pharmacotherapy or may require pharmacological treatment. Conclusions Antidepressant use in pregnancy is well studied, but available research has not yet adequately controlled for other factors that may influence birth outcomes including maternal illness or problematic health behaviors that can adversely affect pregnancy. Keywords: Depression; Pregnancy; Antidepressant agents

Objective: To address the maternal and neonatal risks of both depression and antidepressant exposure and develop algorithms for periconceptional and antenatal management. Method: Representatives from the American Psychiatric Association, the American College of Obstetricians and Gynecologists and a consulting developmental pediatrician collaborated to review English language articles on fetal and neonatal outcomes associated with depression and antidepressant treatment during childbearing. Articles were obtained from Medline searches and bibliographies. Search keywords included pregnancy, pregnancy complications, pregnancy outcomes, depressive disorder, depressive disorder/dt, abnormalities/ drug-induced/epidemiology, abnormalities/drug-induced/et. Iterative draft manuscripts were reviewed until consensus was achieved. Results: Both depressive symptoms and antidepressant exposure are associated with fetal growth changes and shorter gestations, but the majority of studies that evaluated antidepressant risks were unable to control for the possible effects of a depressive disorder. Short-term neonatal irritability and neurobehavioral changes are also linked with maternal depression and antidepressant treatment. Several studies report fetal malformations in association with first trimester antidepressant exposure but there is no specific pattern of defects for individual medications or class of agents. The association between paroxetine and cardiac defects is more often found in studies that included all malformations rather than clinically significant malformations. Late gestational use of selective serotonin reuptake inhibitor antidepressants is associated with transitory neonatal signs and a low risk for persistent pulmonary hypertension in the newborn. Psychotherapy alone is an appropriate treatment for some pregnant women; however, others prefer pharmacotherapy or may require pharmacological treatment. Conclusions: Antidepressant use in pregnancy is well studied, but available research has not yet adequately controlled for other factors that may influence birth outcomes including maternal illness or problematic health behaviors that can adversely affect pregnancy.

Objective. To explore the extent to which pregnant women understand the symptoms and potential complications related to preeclampsia and to determine the factors that are associated with better understanding. Methods. This was a cross-sectional study in which 112 pregnant patients were interviewed to determine their preeclampsia knowledge. Knowledge was evaluated using a 25-item survey addressing the symptoms, consequences, and proper patient actions associated with preeclampsia. Patients were also asked in an open-ended question to define preeclampsia; all responses were rated by three obstetricians. Information about demographics, medical and obstetrical history, and health literacy was also obtained. Health literacy was assessed using the short Test of Functional Health Literacy in Adults (S-TOFHLA). Results. Patients correctly answered only 43% of the 25 questions assessing preeclampsia knowledge. Moreover, only 14% of the patients were able to provide a definition that correctly reflected the syndrome. Factors associated with a greater proportion of correct answers on the questionnaire were higher literacy, multiparity, history of preeclampsia, and receipt of information about preeclampsia from a clinician or another information source (e.g., the Internet, television, a book, or a friend). Conclusions. Pregnant patients have a generally poor understanding of preeclampsia, although improved understanding is associated with having received information about the disease. Further investigation will be needed to determine how best to educate patients and whether this education can also decrease adverse outcomes associated with this syndrome. Posted online:(doi:10.3109/10641955.2010.507851)

OBJECTIVE: To determine the incidence, indications, risk factors, and complications of emergency peripartum hysterectomy.
STUDY DESIGN: A retrospective study of the patients requiring an emergency peripartum hysterectomy of a 9-year period was conducted. Emergency peripartum hysterectomy was defined as one performed for hemorrhage unresponsive to other treatment less than 24 h after delivery. Demographic and clinical variables were obtained from the maternal records.
RESULTS: There were 34 emergency peripartum hysterectomies out of 117,095 deliveries for a rate of 0.29 per 1,000. Of the 16 cases that were delivered by cesarean section, seven had a previous cesarean section and 18 cases were delivered vaginally, including two using vacuum extraction. Total hysterectomy was performed in 24 patients, and subtotal hysterectomy in ten patients. The indications for hysterectomy were uterine rupture (n=12), placenta accreta (n=10), uterine atony (n=7), and hemorrhage (n=5). There were two maternal deaths, six stillbirths, and two early neonatal deaths.
CONCLUSION: This study identified surgical deliveries, uterine rupture, placenta accreta, and uterine atony as risk factors for emergency peripartum hysterectomy. The most common reason for abnormal placental adherence was a previous cesarean section. Multiparity and oxytocin use for uterine stimulation were among the risk factors for uterine atony that necessitated emergency peripartum hysterectomy.

INTRODUCTION: Obstetric patients are generally young and healthy. However, the potential for catastrophic complications is real, and despite the therapeutic advances of the last few decades, maternal morbidity and mortality continue to occur. This may be related to the pregnancy itself, aggravation of a preexisting illness, or complications of the (operative) delivery.
PURPOSE: The purpose of this review is two-fold: first, to provide an update on currently available reports pertaining to important critical care issues of the obstetric patient population and, second, to present current comprehensive treatment options for preeclampsia and massive obstetric hemorrhage because both are responsible for the majority of maternal mortality and morbidity worldwide.
RESULTS: The most common reasons for intensive care unit admission are hypertensive disorders and massive obstetric hemorrhage. Timely delivery and prompt initiation of antihypertensive therapy for severe hypertension form the mainstay of care in preeclampsia. Restoration of circulating blood volume and rapid control of bleeding and impaired coagulation are the main factors in the management of massive obstetric hemorrhage. Puerperal morbidity has become the main topic of quality of care issues in maternity care. Although the Acute Physiology and Chronic Health Evaluation II score is commonly used in the intensive care unit, it does not seem to be appropriate for pregnant women because it overestimates their mortality rates. A high-dependency care unit suits the needs for at least half of the obstetric patient population in need of higher acuity care and will save considerable cost.
CONCLUSION: Emphasis on early detection of maternal problems and prompt referral to tertiary centers with intensive care unit facilities to provide optimum care of the circulation, blood pressure, and respiration at an early stage could minimize the prevalence of multiple organ failure and mortality in critically ill obstetric patients.

Objective: To assess incidence, case fatality rate, risk factors and substandard care in severe maternal morbidity in the Netherlands. Design Prospective population-based cohort study. Setting: All 98 maternity units in the Netherlands. Population: All pregnant women in the Netherlands. Methods: Cases of severe maternal morbidity were collected during a 2-year period. All pregnant women in the Netherlands in the same period acted as reference cohort (n = 371 021). As immigrant women are disproportionately represented in Dutch maternal mortality statistics, special attention was paid to the ethnic background. In a subset of 2.5% of women, substandard care was assessed through clinical audit. Main outcome measures: Incidence, case fatality rates, possible risk factors and substandard care. Results: Severe maternal morbidity was reported in 2552 women, giving an overall incidence of 7.1 per 1000 deliveries. Intensive care unit admission was reported in 847 women (incidence 2.4 per 1000), uterine rupture in 218 women (incidence 6.1/10 000), eclampsia in 222 women (incidence 6.2/10 000) and major obstetric haemorrhage in 1606 women (incidence 4.5 per 1000). Non-Western immigrant women had a 1.3-fold increased risk of severe maternal morbidity (95% CI 1.2–1.5) when compared with Western women. Overall case fatality rate was 1 in 53. Substandard care was found in 39 of a subset of 63 women (62%) through clinical audit. Conclusions: Severe maternal morbidity complicates at least 0.71% of all pregnancies in the Netherlands, immigrant women experiencing an increased risk. Since substandard care was found in the majority of assessed cases, reduction of severe maternal morbidity seems a mandatory challenge.

ABSTRACT: There is enormous geographic variation in the use of cesarean delivery: For births over 2,500 grams, adjusted cesarean rates vary fourfold between low- and high-use areas. Even for births under 2,500 grams, high-use counties have rates that are double those of low-use ones. Higher cesarean rates are only partially explained by patient characteristics but are greatly influenced by nonmedical factors such as provider density, the capacity of the local health care system, and malpractice pressure. Areas with higher usage rates perform the intervention in medically less appropriate populations—that is, relatively healthier births—and do not see improvements in maternal or neonatal mortality.

Findings from recent Canadian studies on the knowledge and beliefs about birth practices among first-time pregnant women and among obstetricians and other birth providers indicate that many women are inadequately informed and many providers deliver non-evidence-based maternity care. Consequently, informed decision making is problematic for pregnant women and their providers. New strategies are needed to inform pregnant women about key procedures and approaches that might be used in birth so they can have an educated, shared discussion with their provider and successfully advocate for their preferred birth experience. In addition, providers can be encouraged to supplement their knowledge with current, evidence-based maternity care practices. To avoid a lack of informed decision making and to ensure that natural, safe, and healthy birth practices are based on current evidence, pregnant women and providers must work together to inform themselves and to add childbirth to the women’s health agenda.

An overview of the role of the California Maternal Quality Care Collaborative (CMQCC) to reduce the rising rates of maternal mortality and the associated increase in maternal morbidity in the state of California. The innovative connection of a quality improvement collaborative with the California Pregnancy-Related and Pregnancy-Associated Mortality Review committee facilitates the more rapid diffusion of findings into action.

A reasonable trigger tool for nursing charting on L&D. From: Appendix to Saving Mother's Lives (2007); also published in: International Journal of Obstetric Anesthesia (2006) 15, S1-S43 Abstracts of free papers presented at the annual meeting of the Obstetric Anaesthetists? Association, Glasgow 11-12 May, 2006. “Early-warning scoring in obstetrics”. P Harrison, C Hawe, F McIlveney. Department of Anaesthesia, Stirling Royal Infirmary, Stirling, UK.

Depression is the leading cause of disability for women in their childbearing years. As many as one in five women in BC will experience significant depression in relation to her pregnancy and childbirth. Unfortunately,few of these women seek help. Without treatment, perinatal depression affects all aspects of a woman’s health and that of her baby. It can be a factor leading to low birth weight, compromised motherinfant-interaction, and behavioural/cognitive impairment in early preschool years. The most tragic consequences of perinatal depression are maternal suicide and infanticide. Although perinatal depression is a serious illness, with the right strategy and a coordinated approach it can be detected early and effectively treated. This document outlines a framework for action to improve recognition, diagnosis, treatment and follow-up care for women affected by perinatal depression in BC.

My focus is on post partum hemorrhage (PPH) and emergency hysterectomy (this is commonly called “the ordeal” by the women who have experienced it) is driven by a desire to understand several interwoven questions, 1) what takes place during the ordeal and how embodied knowledge is disjointed and ruptured, 2) how women recreate embodied wholeness through narrative and defining the ordeal, and 3) how women create healing and resiliency through collective empathy and a redefine family through various means. PPH often results in death or near death experiences as a result of various complications brought on from hemorrhaging.