US Trends in Drug Overdose Mortality Among Pregnant and Postpartum Persons, 2017-2020.

This study evaluates changes in overall and drug-specific overdose mortality among pregnant and postpartum persons before and during the COVID-19 pandemic.

Impact of autoantibodies against the M2-muscarinic acetylcholine receptor on clinical outcomes in peripartum cardiomyopathy patients with standard treatment.

OBJECTIVES: To evaluate the impact of autoantibodies against the M2-muscarinic receptor (anti-M2-R) on the clinical outcomes of patients receiving the standard treatment for peripartum cardiomyopathy (PPCM). METHODS: A total of 107 PPCM patients who received standard heart failure (HF) treatment between January 1998 and June 2020 were enrolled in this study. According to anti-M2-R reactivity, they were classified into negative (n = 59) and positive (n = 48) groups, denoted as the anti-M2-R (-) and anti-M2-R (+) groups. Echocardiography, 6-min walk distance, serum digoxin concentration (SDC), and routine laboratory tests were performed regularly for 2 years. The all-cause mortality, cardiovascular mortality, and rehospitalisation rate for HF were compared between the two groups. RESULTS: A total of 103 patients were included in the final data analysis, with 46 in the anti-M2-R (+) group and 57 in the anti-M2-R (-) group. Heart rate was lower in the anti-M2-R (+) group than in the anti-M2-R (-) group at the baseline (102.7 ± 6.1 bpm vs. 96.0 ± 6.4 bpm, p < 0.001). The initial SDC was higher in the anti-M2-R (+) group than in the anti-M2-R (-) group with the same dosage of digoxin (1.25 ± 0.45 vs. 0.78 ± 0.24 ng/mL, p < 0.001). The dosages of metoprolol and digoxin were higher in the anti-M2-R (-) patients than in the anti-M2-R (+) patients (38.8 ± 4.6 mg b.i.d. vs. 27.8 ± 5.3 mg b.i.d., p < 0.0001, respectively, for metoprolol; 0.12 ± 0.02 mg/day vs. 0.08 ± 0.04 mg/day, p < 0.0001, respectively, for digoxin). Furthermore, there was a greater improvement in cardiac function in the anti-M2-R (-) patients than in the anti-M2-R (+) patients. Multivariate analysis identified negativity for anti-M2-R as the independent predictor for the improvement of cardiac function. Rehospitalisation for HF was lower in the anti-M2-R (-) group, but all-cause mortality and cardiovascular mortality were the same. CONCLUSIONS: There were no differences in all-cause mortality or cardiovascular mortality between the two groups. Rehospitalisation rate for HF decreased in the anti-M2-R (-) group. This difference may be related to the regulation of the autonomic nervous system by anti-M2-R.

Maternal and Neonatal Outcomes of Critically Ill Pregnant and Puerperal Patients Diagnosed with COVID-19 Disease: Retrospective Comparative Study.

BACKGROUND: We assessed maternal and neonatal outcomes of critically ill pregnant and puerperal patients in the clinical course of coronavirus disease 2019 (COVID-19). METHODS: Records of pregnant and puerperal women with polymerase chain reaction positive COVID-19 virus who were admitted to our intensive care unit (ICU) from March 2020 to August 2021 were investigated. Demographic, clinical and laboratory data, pharmacotherapy, and neonatal outcomes were analyzed. These outcomes were compared between patients that were discharged from ICU and patients who died in ICU. RESULTS: Nineteen women were included in this study. Additional oxygen was required in all cases (100%). Eight patients (42%) were intubated and mechanically ventilated. All patients that were mechanically ventilated have died. Increased levels of C-reactive protein (CRP) was seen in all patients (100%). D-dimer values increased in 15 patients (78.9%); interleukin-6 (IL-6) increased in 16 cases (84.2%). Sixteen patients used antiviral drugs. Eleven patients were discharged from the ICU and eight patients have died due to complications of COVID-19 showing an ICU mortality rate of 42.1%. Mean number of hospitalized days in ICU was significantly lower in patients that were discharged (P = 0.037). Seventeen patients underwent cesarean-section (C/S) (89.4%). Mean birth week was significantly lower in patients who died in ICU (P = 0.024). Eleven preterm (57.8%) and eight term deliveries (42.1%) occurred. CONCLUSION: High mortality rate was detected among critically ill pregnant/parturient patients followed in the ICU. Main predictors of mortality were the need of invasive mechanical ventilation and higher number of days hospitalized in ICU. Rate of C/S operations and preterm delivery were high. Pleasingly, the rate of neonatal death was low and no neonatal COVID-19 occurred.

Impact of the ICD-9-CM to ICD-10-CM transition on the incidence of severe maternal morbidity among delivery hospitalizations in the United States.

BACKGROUND: Surveillance of maternal mortality and severe maternal morbidity is important to identify temporal trends, evaluate the impact of clinical practice changes or interventions, and monitor quality of care. A common source for severe maternal morbidity surveillance is hospital discharge data. On October 1, 2015, all hospitals in the United States transitioned from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding for diagnoses and procedures. OBJECTIVE: This study aimed to evaluate the impact of the transition from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding systems on the incidence of severe maternal morbidity in the United States in hospital discharge data. STUDY DESIGN: Using data from the National Inpatient Sample, obstetrical deliveries between January 1, 2012, and December 31, 2017, were identified using a validated case definition. Severe maternal morbidity was defined using the International Classification of Diseases, Ninth Revision, Clinical Modification (January 1, 2012, to September 30, 2015) and the International Classification of Diseases, Tenth Revision, Clinical Modification (October 1, 2015, to December 31, 2017) codes provided by the Centers for Disease Control and Prevention. An interrupted time series and segmented regression analysis was used to assess the impact of the transition from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding on the incidence of severe maternal morbidity per 1000 obstetrical deliveries. RESULTS: From 22,751,941 deliveries, the incidence of severe maternal morbidity in the International Classification of Diseases, Ninth Revision, Clinical Modification coding era was 19.04 per 1000 obstetrical deliveries and decreased to 17.39 per 1000 obstetrical deliveries in the International Classification of Diseases, Tenth Revision, Clinical Modification coding era (P<.001). The transition to International Classification of Diseases, Tenth Revision, Clinical Modification coding led to an immediate decrease in the incidence of severe maternal morbidity (-2.26 cases of 1000 obstetrical deliveries) (P<.001). When blood products transfusion was removed from the case definition, the magnitude of the decrease in the incidence of SMM was much smaller (-0.60 cases/1000 obstetric deliveries), but still significant (P<.001). CONCLUSION: After the transition to the International Classification of Diseases, Tenth Revision, Clinical Modification coding for health diagnoses and procedures in the United States, there was an abrupt statistically significant and clinically meaningful decrease in the incidence of severe maternal morbidity in hospital discharge data. Changes in the underlying health of the obstetrical population are unlikely to explain the sudden change in severe maternal morbidity. Although much work has been done to validate the International Classification of Diseases, Ninth Revision, Clinical Modification codes for severe maternal morbidity, it is critical that validation studies be undertaken to validate the International Classification of Diseases, Tenth Revision, Clinical Modification codes for severe maternal morbidity to permit ongoing surveillance, quality improvement, and research activities that rely on hospital discharge data.

Clinical Outcomes of Pregnant and Postpartum Extracorporeal Membrane Oxygenation Patients.

BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) as a rescue therapy for cardiopulmonary failure is expanding in critical care medicine. In this case series, we describe the clinical outcomes of 21 consecutive pregnant or postpartum patients that required venovenous (VV) or venoarterial (VA) ECMO. Our objective was to characterize maternal and fetal survival in peripartum ECMO and better understand ECMO-related complications that occur in this unique patient population. METHODS: Between January 2009 and June 2019, all pregnant and postpartum patients treated with ECMO for respiratory or circulatory failure at a single quaternary referral center were identified. For all patients, indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and anticoagulation and bleeding complications were collected. RESULTS: Twenty-one obstetric patients were treated with ECMO over 10 years. Thirteen patients were treated with VV ECMO and 8 patients were treated with VA ECMO. Six patients were pregnant at the time of cannulation and 3 patients delivered while on ECMO; all 6 maternal and infant dyads survived to hospital discharge. The median gestational age at cannulation was 28 weeks (interquartile range [IQR], 24-31). In the postpartum cohort, ECMO initiation ranged from immediately after delivery up to 46 days postpartum. Fifteen women survived (72%). Major bleeding complications requiring surgical intervention were observed in 7 patients (33.3%). Two patients on VV ECMO required bilateral orthotopic lung transplantation and 1 patient on VA ECMO required orthotopic heart transplantation to wean from ECMO. CONCLUSIONS: Survival for mother and neonate are excellent with peripartum ECMO in a high-volume ECMO center. Neonatal and maternal survival was 100% when ECMO was used in the late second or early third trimester. Based on these results, ECMO remains an important treatment option for peripartum patients with cardiopulmonary failure.

Clinical Features and Outcomes of Peripartum Cardiomyopathy in Nigeria.

BACKGROUND: Nigeria has the highest incidence of peripartum cardiomyopathy (PPCM) in the world. However, data on PPCM-related outcomes are limited. OBJECTIVES: The purpose of this study was to examine the clinical profile, myocardial remodeling, and survival of patients with PPCM in Nigeria. METHODS: This study consecutively recruited 244 PPCM patients (median 7 months postpartum) at 14 sites in Nigeria and applied structured follow-up for a median of 17 months (interquartile range: 14 to 20 months). Left ventricular reverse remodeling (LVRR) was defined as the composite of left ventricular (LV) end-diastolic dimension <33 mm/m2 and absolute increase in left ventricular ejection fraction (LVEF) ≥10%. LV full recovery was defined as LVEF ≥55%. RESULTS: Overall, 45 (18.7%) patients died during follow-up. Maternal age <20 years (hazard ratio [HR]: 2.40; 95% confidence interval (CI): 1.27 to 4.54), hypotension (HR: 1.87; 95% CI: 1.02 to 3.43), tachycardia (HR: 2.38; 95% CI: 1.05 to 5.43), and LVEF <25% at baseline (HR: 2.11; 95% CI: 1.12 to 3.95) independently predicted mortality. Obesity (HR: 0.16; 95% CI: 0.04 to 0.55) and regular use of beta-blockers at 6-month follow-up (HR: 0.20; 95% CI: 0.09 to 0.41) were independently associated with reduced risk for mortality. In total, 48 patients (24.1%) achieved LVRR and 45 (22.6%) achieved LV full recovery. LVEF <25% at baseline (HR: 0.66; 95% CI: 0.47 to 0.92) and regular use of beta-blockers at 6-month follow-up (HR: 1.62; 95% CI: 1.17 to 2.25) independently determined the risk for LV full recovery. Progressive reverse remodeling of all cardiac chambers was observed. In total, 18 patients (7.4%) were hospitalized during the study. CONCLUSIONS: This is the largest study of PPCM in Africa. Consistent with late presentations, the mortality rate was high, whereas frequencies of LVRR and LV full recovery were low. Several variables predicted poor outcomes, and regular use of beta-blockers correlated with late survival and LV functional recovery.

Selenium supplementation in patients with peripartum cardiomyopathy: a proof-of-concept trial.

BACKGROUND: We studied the efficacy and safety of selenium supplementation in patients who had peripartum cardiomyopathy (PPCM) and selenium deficiency. METHODS: We randomly assigned 100 PPCM patients with left ventricular ejection fraction (LVEF) < 45% and selenium deficiency (< 70 µg/L) to receive either oral Selenium (L-selenomethionine) 200 µg/day for 3 months or nothing, in addition to recommended therapy, in an open-label randomised trial. The primary outcome was a composite of persistence of heart failure (HF) symptoms, unrecovered LV systolic function (LVEF < 55%) or death from any cause. RESULTS: Over a median of 19 months, the primary outcome occurred in 36 of 46 patients (78.3%) in the selenium group and in 43 of 54 patients (79.6%) in the control group (hazard ratio [HR] 0.69; 95% confidence interval [CI] 0.43-1.09; p = 0.113). Persistence of HF symptoms occurred in 18 patients (39.1%) in the selenium group and in 37 patients (68.5%) in the control group (HR 0.53; 95% CI 0.30-0.93; p = 0.006). LVEF < 55% occurred in 33 patients (71.7%) in the selenium group and in 38 patients (70.4%) in the control group (HR 0.91; 95% CI 0.57-1.45; p = 0.944). Death from any cause occurred in 3 patients (6.5%) in the selenium group and in 9 patients (16.7%) in the control group (HR 0.37; 95% CI 0.10-1.37; p = 0.137). CONCLUSIONS: In this study, selenium supplementation did not reduce the risk of the primary outcome, but it significantly reduced HF symptoms, and there was a trend towards a reduction of all-cause mortality. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03081949.

Standardized Criteria for Review of Perinatal Suicides and Accidental Drug-Related Deaths.

OBJECTIVE: To estimate the proportion of accidental drug-related deaths and suicides classified as pregnancy-related from 2013 to 2014 (preimplementation of standardized criteria) and 2015 to 2016 (postimplementation). METHODS: Based on Centers for Disease Control and Prevention pregnancy-related death criteria, the Utah Perinatal Mortality Review Committee developed a standardized evaluation tool to assess accidental drug-related death and suicide beginning in 2015. We performed a retrospective case review of all pregnancy-associated deaths (those occurring during pregnancy or 1 year postpartum for any reason) and pregnancy-related deaths (those directly attributable to the pregnancy or postpartum events) evaluated by Utah's Perinatal Mortality Review Committee from 2013 to 2016. We compared the proportion of accidental drug-related deaths and suicides meeting pregnancy-related criteria preimplementation and postimplementation of a standardized criteria checklist tool using Fisher's exact test. We assessed the change in pregnancy-related mortality ratio in Utah from 2013 to 2014 and 2015 to 2016 using test of trend. RESULTS: From 2013 to 2016, there were 80 pregnancy-associated deaths in Utah (2013-2014: n=40; 2015-2016: n=40), and 41 (51%) were pregnancy-related (2013-2014: n=15, 2015-2016: n=26). In 2013-2014 (preimplementation), 12 women died of drug-related deaths or suicides, and only two of these deaths were deemed pregnancy-related (17%). In 2015-2016 (postimplementation), 18 women died of drug-related deaths or suicide, and 94% (n=17/18) of these deaths met one or more of the pregnancy-related criteria on the checklist (P<.001). From 2013 to 2014 to 2015-2016, Utah's overall pregnancy-related mortality ratio more than doubled, from 11.8 of 100,000 to 25.7 of 100,000 (P=.08). CONCLUSION: After application of standardized criteria, the Utah Perinatal Mortality Review Committee determined that pregnancy itself was the inciting event leading to the majority of accidental drug-related deaths or suicides among pregnant and postpartum women. Other maternal mortality review committees may consider a standardized approach to assessing perinatal suicides and accidental drug-related deaths.

Clinical characteristics and risk factors for mortality in obstetric patients with severe COVID-19 in Brazil: a surveillance database analysis.

OBJECTIVE: To describe clinical characteristics of pregnant and postpartum women with severe COVID-19 in Brazil and to examine risk factors for mortality. DESIGN: Cross-sectional study based on secondary surveillance database analysis. SETTING: Nationwide Brazil. POPULATION OR SAMPLE: 978 Brazilian pregnant and postpartum women notified as COVID-19 Acute Respiratory Distress Syndrome (ARDS) cases with complete outcome (death or cure) up to 18 June 2020. METHODS: Data was abstracted from the Brazilian ARDS Surveillance System (ARDS-SS) database. All eligible cases were included. Data on demographics, clinical characteristics, intensive care resources use and outcomes were collected. Risk factors for mortality were examined by multivariate logistic regression. MAIN OUTCOME MEASURES: Case fatality rate. RESULTS: We identified 124 maternal deaths, corresponding to a case fatality rate among COVID-19 ARDS cases in the obstetric population of 12.7%. At least one comorbidity was present in 48.4% of fatal cases compared with 24.9% in survival cases. Among women who died, 58.9% were admitted to ICU, 53.2% had invasive ventilation and 29.0% had no respiratory support. The multivariate logistic regression showed that the main risk factors for maternal death by COVID-19 were being postpartum at onset of ARDS, obesity, diabetes and cardiovascular disease, whereas white ethnicity had a protective effect. CONCLUSIONS: Negative outcomes of COVID-19 in this population are affected by clinical characteristics but social determinants of health also seem to play a role. It is urgent to reinforce containment measures targeting the obstetric population and ensure high quality care throughout pregnancy and the postpartum period. TWEETABLE ABSTRACT: A total of 124 COVID-19 maternal deaths were identified in Brazil. Symptoms onset at postpartum and comorbidities are risk factors.

Extracorporeal Life Support in Pregnancy: A Systematic Review.

Background The use of extracorporeal life support (ECLS) has expanded to include unique populations such as peripartum women. This systematic review aims to (1) quantify the number of cases and indications for ECLS in women during the peripartum period reported in the literature and (2) report maternal and fetal complications and outcomes associated with peripartum ECLS. Methods and Results This review was registered in PROSPERO (CRD42018108142). MEDLINE, Embase, and CINAHL were searched for case reports, case series, and studies reporting cases of ECLS during the peripartum period that reported one or more of the following outcomes: maternal survival, maternal complications, fetal survival, and/or fetal complications. Qualitative assessment of 221 publications evaluated the number of cases, clinical details, and maternal and fetal outcomes of ECLS during the peripartum period. There were 358 women included and 68 reported fetal outcomes in cases where the mother was pregnant at the time of cannulation. The aggregate maternal survival at 30 days was 270 (75.4%) and at 1 year was 266 (74.3%); fetal survival was 44 (64.7%). The most common indications for ECLS overall in pregnancy included acute respiratory distress syndrome 177 (49.4%), cardiac failure 67 (18.7%), and cardiac arrest 57 (15.9%). The most common maternal complications included mild to moderate bleeding 66 (18.4%), severe bleeding requiring surgical intervention 48 (13.4%), and intracranial neurologic morbidity 19 (5.3%). The most commonly reported fetal complications included preterm delivery 33 (48.5%) and neonatal intensive care unit admission 19 (27.9%). Conclusions Reported rates of survival in ECLS in pregnant and postpartum women are high and major complications relatively low.

Prognostic nutritional index as a novel marker for prediction of prognosis in patients with peripartum cardiomyopathy.

The clinical significance of poor nutritional status in patients with peripartum cardiomyopathy (PPCM) is not clearly understood. Prognostic nutritional index (PNI) is a simple nutritional assessment tool, which was first demonstrated to be valuable in patients with colorectal surgeries. We aimed to investigate the predictive value of PNI in patients with PPCM.A total of 92 patients diagnosed with PPCM were enrolled in this study. PNI was calculated using the following formula: 10 × serum albumin value (g/dL) + 0.005 × total lymphocyte count. The primary endpoint was defined as composite adverse cardiac events that included cardiac death or hospitalization due to worsening heart failure (HF). Cardiac death, hospitalization due to worsening HF, and persistent left ventricular (LV) systolic dysfunction were evaluated, respectively, as secondary endpoints.Primary composite endpoint was higher in the lower PNI group. After adjusting for other risk factors, PNI was found to be as an independent predictor of primary composite endpoint (odds ratio 0.805; 95% confidence interval 0.729-0.888; P < .001). In addition, PNI was significantly associated with secondary endpoints; persistent LV systolic dysfunction as well as cardiac death.This study identified nutritional status assessed by the PNI seems to be a novel predictor of adverse cardiovascular outcomes in patients with PPCM.

Acute Stroke During Pregnancy and Puerperium.

BACKGROUND: Acute stroke during pregnancy or within 6 weeks of childbirth is devastating for the mother and her family, yet data regarding incidence and contemporary trends are very limited. OBJECTIVES: This study sought to investigate the incidence and outcomes of acute stroke and transient ischemic attack during pregnancy or within 6 weeks of childbirth in a large database. METHODS: The National Inpatient Sample was queried to identify women age ≥18 years in the United States with pregnancy-related hospitalizations from January 1, 2007, to September 30, 2015. Temporal trends in acute stroke (ischemic and hemorrhagic)/transient ischemic attack incidence and in-hospital mortality were extracted. RESULTS: Among 37,360,772 pregnancy-related hospitalizations, 16,694 (0.045%) women had an acute stroke. The rates of acute stroke did not change (42.8 per 100,000 hospitalizations in 2007 vs. 42.2 per 100,000 hospitalizations in 2015; ptrends = 0.10). Among those with acute stroke, there were increases in prevalence of obesity, smoking, hyperlipidemia, migraine, and gestational hypertension. Importantly, in-hospital mortality rates were almost 385-fold higher among those who had a stroke (42.1 per 1,000 pregnancy-related hospitalizations vs. 0.11 per 1,000 pregnancy-related hospitalizations; p < 0.0001). The rates of in-hospital mortality among pregnant women with acute stroke decreased (5.5% in 2007 vs. 2.7% in 2015; ptrends < 0.001). CONCLUSIONS: In this contemporary analysis of pregnancy-related hospitalizations, acute stroke occurred in 1 of every 2,222 hospitalizations, and these rates did not decrease over approximately 9 years. The prevalence of most stroke risk factors has increased. Acute stroke during pregnancy and puerperium was associated with high maternal mortality, although it appears to be trending downward. Future studies to better identify mechanisms and approaches to prevention and management of acute stroke during pregnancy and puerperium are warranted.

Predictors of early and delayed recovery in peripartum cardiomyopathy: a prospective study of 52 Patients.

Background: Predictors of early or delayed recovery are unclear in peripartum cardiomyopathy (PPCM). Therefore, we aimed to assess the prognostic value of serial assessment of clinical, echocardiographic, and biochemical markers in patients with PPCM.Methods: Fifty-two consecutive women with PPCM were enrolled in this prospective study. Each patient underwent transthoracic echocardiography, B-type natriuretic peptide (BNP) and C-reactive protein (CRP) measurement at admission, and every 3 months. Early recovery was defined as resolution of heart failure at 6 months postdiagnosis, delayed recovery was defined if the length of time required for recovery of left ventricular function was longer than 6 months, and persistent left ventricular dysfunction (PLVD) was defined as an ejection fraction of less than 50% at the end of follow-up.Results: Thirty patients (57.7%) recovered completely, 10 died (19.2%), and 12 (23.1%) had PLVD. There were no significant differences in baseline BNP and CRP values between patients who recovered completely and who did not recover. However, patients with complete recovery were more likely to have a higher left ventricular ejection fraction, smaller left ventricle end-systolic dimensions at baseline, and lower CRP and BNP levels at follow-up. Elevated levels of BNP and CRP on follow up at 3 and 6 months were associated with nonrecovery. Third and sixth month BNP values were significantly lower in patients with rapid recovery, compared to patients with delayed recovery. Bromocriptine therapy was also associated with early recovery.Conclusions: Persistent elevation of plasma CRP and BNP levels at follow-up portend a slower response or nonrecovery in patients with PPCM. Bromocriptine therapy was an independent predictor of early recovery.

The way to move beyond the numbers: the lesson learnt from the Italian Obstetric Surveillance System.

OBJECTIVE: To describe the Italian Obstetric Surveillance System (ItOSS) investigating maternal death through incident case reporting and confidential enquiries. METHODS: All maternal deaths occurred in any public and private health facility in 8 Italian regions covering 73% of national births have been notified to the ItOSS. Every incident case is confidentially reviewed to assess quality of care and establish the cause and avoidability of the death. FINDINGS: A total of 106 maternal deaths among 1 455 545 live births have been notified to the surveillance system in 2013-17. Haemorrhage, sepsis and hypertensive disorders of pregnancy are the leading causes of direct maternal deaths due to obstetric causes. CONCLUSIONS: A maternal mortality surveillance system, including incidence reporting and confidential enquiries along with a retrospective analysis of administrative data sources, emerged as the best option for case ascertainment and for preventing avoidable maternal deaths.

Cardiomyopathy and pregnancy.

Cardiomyopathy is a group of disorders in which the heart muscle is structurally and functionally abnormal in the absence of other diseases that could cause observed myocardial abnormality. The most common cardiomyopathies are hypertrophic and dilated cardiomyopathy. Rare types are arrhythmogenic right ventricular, restrictive, Takotsubo and left ventricular non-compaction cardiomyopathies. This review of cardiomyopathies in pregnancy shows that peripartum cardiomyopathy is the most common cardiomyopathy in pregnancy. Peripartum cardiomyopathy develops most frequently in the month before or after partum, whereas dilated cardiomyopathy often is known already or develops in the second trimester. Mortality in peripartum cardiomyopathy varies from <2% to 50%. Few reports on dilated cardiomyopathy and pregnancy exist, with only a limited number of patients. Ventricular arrhythmias, heart failure, stroke and death are found in 39%-60% of high-risk patients. However, patients with modest left ventricular dysfunction and good functional class tolerated pregnancy well. Previous studies on >700 pregnancies in 500 women with hypertrophic cardiomyopathy showed that prognosis was generally good, even though three deaths were reported in high-risk patients. Complications include different types of supraventricular and ventricular arrhythmias, heart failure and ischaemic stroke. Recent studies on 200 pregnancies in 100 women with arrhythmogenic right ventricular cardiomyopathy have reported symptoms, including heart failure in 18%-33% of pregnancies. Ventricular tachycardia was found in 0%-33% of patients and syncope in one patient. Information on rare cardiomyopathies is sparse and only presented in case reports. Close monitoring by multidisciplinary teams in referral centres that counsel patients before conception and follow them throughout gestation is recommended.

Electrocardiographic findings in peripartum cardiomyopathy.

BACKGROUND: There is limited data on electrocardiographic (ECG) abnormalities and their prognostic significance in women with peripartum cardiomyopathy (PPCM). We sought to characterize ECG findings in PPCM and explore the association of ECG findings with myocardial recovery and clinical outcomes. HYPOTHESIS: We hypothesized that ECG indicators of myocardial remodeling would portend worse systolic function and outcomes. METHODS: Standard 12-lead ECGs were obtained at enrollment in the Investigations of Pregnancy-Associated Cardiomyopathy study and analyzed for 88 women. Left ventricular ejection fraction (LVEF) was measured by echocardiography at baseline, 6 months, and 12 months. Women were followed for clinical events (death, mechanical circulatory support, and/or cardiac transplantation) until 1 year. RESULTS: Half of women had an "abnormal" ECG, defined as atrial abnormality, ventricular hypertrophy, ST-segment deviation, and/or bundle branch block. Women with left atrial abnormality (LAA) had lower LVEF at 6 months (44% vs 52%, P = 0.02) and 12 months (46% vs 54%, P = 0.03). LAA also predicted decreased event-free survival at 1 year (76% vs 97%, P = 0.008). Neither left ventricular hypertrophy by ECG nor T-wave abnormalities predicted outcomes. A normal ECG was associated with recovery in LVEF to ≥50% (84% vs 49%, P = 0.001) and event-free survival at 1 year (100% vs 85%, P = 0.01). CONCLUSIONS: ECG abnormalities are common in women with PPCM, but a normal ECG does not rule out the presence of PPCM. LAA predicted lower likelihood of myocardial recovery and event-free survival, and a normal ECG predicted favorable event-free survival.

Examination of a death due to cardiomyopathy by a maternal mortality review committee.

Deaths related to pregnancy were relatively common in the United States at the beginning of the twentieth century. A dramatic reduction of 99% in maternal mortality rate, from 850.0-7.5 per 100,000 live births from 1900-1982, is 1 of the most noteworthy public health success stories of the time period. This plateau continued until the late 1990s when the maternal mortality rate began to rise again. The reasons for this increase are unclear. Vital statistics data alone cannot answer the many questions surrounding this increase. The need for detailed and reliable information about causes of death and underlying factors has led to the development of state- and urban-based maternal death reviews. Although processes may vary, an expert panel is convened to review individual cases and make recommendations for systems change. Review of maternal deaths is considered to be a core public health function. There are multiple purposes for this article. The first goal is to highlight the components of a maternal mortality review. The second goal is to provide an example for new review committees. A mock case of cardiomyopathy is used to illustrate both the process and development of actionable recommendations for clinical intervention. Recommendations to address community- and system-level contributing factors and the social determinants of health are discussed. The third goal is to educate providers regarding presentation and management of cardiomyopathy. Fourth, it is hoped that policymakers in the area of maternal health and facilities that review maternal morbidity and mortality rates at the institutional level will find the article useful as well. Finally, the article provides facility-level committees with a process example for review of the circumstances of maternal deaths beyond clinical factors so that they may make recommendations to address nonclinical contributors to pregnancy-related deaths. Documenting both clinical and nonclinical contributors to maternal death are critical to influence public opinion, develop coalitions for collective impact, and engage at risk populations in proposing interventions.

Perinatal outcomes according to the mode of delivery in women with a triplet pregnancy in The Netherlands.

Objective: In women with a triplet pregnancy, there is debate on the preferred mode of delivery. We performed a nationwide cohort study to assess the impact of mode of delivery on perinatal outcome in women with a triplet pregnancy. Methods: Nationwide cohort study on women with a triplet pregnancy who delivered between 26 + 0 and 40 + 0 weeks of gestation in the years 1999-2008. We compared perinatal outcomes according to the intended mode of delivery and the actual mode of delivery. Outcome measures were perinatal mortality and neonatal morbidity. Perinatal outcomes were analyzed taking into account the dependency between the children of the same triplet pregnancy ("any mortality" and "any morbidity") and were also analyzed separately per child. Results: We identified 386 women with a triplet pregnancy in the study period. Mean gestational age at delivery was 33.1 weeks (SD 2.5 weeks; range 26.0-40.0 weeks). Perinatal mortality was 2.3% for women with a planned caesarean section and 2.4% in women with a planned vaginal delivery (aOR 0.37; 95% confidence interval (CI) 0.09-1.5) and neonatal morbidity was 26.0% versus 36.0%, (aOR 0.88; 95% CI 0.51-1.4) respectively. In the subgroup analyses according to gestational age and in the analysis of perinatal outcomes per child separately, there were also no large differences in perinatal outcomes. The same applied for perinatal outcomes according to the actual mode of delivery. Conclusion: In this large cohort study among women with a triplet pregnancy, caesarean delivery is not associated with reduced perinatal mortality and morbidity.