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The Third Wish Carolyn Brown
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Contributors
CONSULTINGEDITOR
WILLIAMF.RAYBURN,MD,MBA
AssociateDean,ContinuingMedicalEducationandProfessionalDevelopment, DistinguishedProfessorandEmeritusChair,ObstetricsandGynecology,Universityof NewMexicoSchoolofMedicine,Albuquerque,NewMexico
EDITORS
ERIKAPETERSON,MD
AssociateProfessor,DepartmentofObstetricsandGynecology,Director,Divisionof Maternal-FetalMedicine,Co-DirectorFetalConcernsCenterofWisconsin,Medical CollegeofWisconsin,Milwaukee,Wisconsin
JUDITHU.HIBBARD,MD
ProfessorEmeritus,Professor,ViceChair,DepartmentofObstetricsandGynecology, DivisionofMaternal-FetalMedicine,MedicalCollegeofWisconsin,Milwaukee,Wisconsin
AUTHORS
KASSIEJ.BOLLIG,MD
ResidentPhysician,DepartmentofObstetrics,GynecologyandWomen’sHealth, UniversityofMissouriSchoolofMedicine,Columbia,Missouri
JOANBRILLER,MD
ProfessorofMedicine,DirectoroftheHeartDiseaseinWomenProgram,Divisionof Cardiology,Professor,DepartmentofObstetricsandGynecology,UniversityofIllinoisat Chicago,Chicago,Illinois
SABRINACRAIGO,MD
ProfessorofObstetricsandGynecology,DirectorofMaternal-FetalMedicine,Tufts UniversitySchoolofMedicine,TuftsMedicalCenter,Boston,Massachusetts
MEREDITHO.CRUZ,MD,MPH,MBA
AssistantProfessor,DepartmentofObstetricsandGynecology,DivisionofMaternal-Fetal Medicine,MedicalCollegeofWisconsin,Milwaukee,Wisconsin
JEFFREYM.DENNEY,MD,MS,FACOG
AssistantProfessor,DepartmentofObstetricsandGynecology,Sectionof Maternal-FetalMedicine,WakeForestUniversitySchoolofMedicine,Winston-Salem, NorthCarolina
CARAD.DOLIN,MD
DivisionofMaternal-FetalMedicine,DepartmentofObstetricsandGynecology,NewYork UniversityLangoneHealth,NewYork,NewYork
NEETAL.VORA,MD
DivisionofMaternal-FetalMedicine,DepartmentofObstetricsandGynecology, UniversityofNorthCarolinaatChapelHillSchoolofMedicine,ChapelHill,NorthCarolina
CHLOEZERA,MD,MPH
AssistantProfessor,DivisionofMaternal-FetalMedicine,BrighamandWomen’s Hospital,HarvardMedicalSchool,Boston,Massachusetts
Contents
Foreword:Team-BasedCareofPregnantWomenwithChallenging MedicalDisorders xiii
WilliamF.Rayburn
Preface:MedicalDisordersinPregnancyxv ErikaPetersonandJudithU.Hibbard
MaternalMortalityintheTwenty-FirstCentury175
JohnA.OzimekandSarahJ.Kilpatrick
Maternalmortalityplaguesmuchoftheworld.Therewere303,000maternal deathsin2015representinganoverallglobalmaternalmortalityratioof216 maternaldeathsper100,000livebirths.IntheUnitedStates,thematernal mortalityratiohadbeendecreasinguntil1987,remainedstableuntil1999, andthenbegantoincrease.Racialdisparitiesexistintheratesofmaternal mortalityintheUnitedStates,withmaternaldeathaffectingahigherproportionofblackwomencomparedwithwhitewomen.Toreducematernal mortality,nationalorganizationsintheUnitedStateshavecalledforstandardizedreviewofcasesofmaternalmorbidityandmortality.
CancerinPregnancy187
AnnaMcCormickandErikaPeterson
Thisarticlereviewssomeofthemorecommontypesofcancerthatmaybe encounteredduringpregnancy.Itreviewstheuniquechallengeswiththe diagnosisandtreatmentofbreast,cervical,hematologic,andcoloncancersinpregnantpatients.
OpioidUseDisordersandPregnancy201
AmandaJ.JohnsonandCrestaW.Jones
Opioidusedisorderpresentsanincreasedriskofcomplicationsinpregnancy,particularlywhenuntreated.Tooptimizeoutcomes,medicationassistedtreatmentusingmethadoneorbuprenorphineasapartofa comprehensivecaremodelisrecommended.Neonatalabstinencesyndromeandpoorfetalgrowthremainsignificantcomplicationsofthisdisorderdespitematernaltreatment.
PregnancyinWomenwithObesity217
CaraD.DolinandMichelleA.Kominiarek
Pregnancyinwomenwithobesityisanimportantpublichealthproblemwith short-andlong-termimplicationsformaternalandchildhealth.Obesity complicatesalmostallaspectsofpregnancy.Giventhegrowingprevalence ofobesityinwomen,obstetricprovidersneedtounderstandtherisksassociatedwithobesityinpregnancyandtheuniqueaspectsofmanagementfor
womenwithobesity.Empathicandpatient-centeredcare,alongwithknowledge,canoptimizeoutcomesforwomenandchildren.
ManagementofObstructiveSleepApneainPregnancy233
JenniferE.Dominguez,LindaStreet,andJudetteLouis
Thespectrumofsleep-disorderedbreathing(SDB)rangesfrommildsnoringtoobstructivesleepapnea,themostsevereformofSDB.Currentrecommendationsaretotreatthesewomenwithcontinuouspositiveairway pressuredespitelimiteddata.SDBinearlyandmidpregnancyisassociatedwithpreeclampsiaandgestationaldiabetes.Pregnantwomenwitha diagnosisofobstructivesleepapneaatdeliverywereatsignificantly increasedriskofhavingcardiomyopathy,congestiveheartfailure,pulmonaryembolism,andin-hospitaldeath.Theseeffectswereexacerbatedin thepresenceofobesity.Postpartum,thesewomenareatriskforrespiratorysuppressionandshouldbemonitored.
MaternalGeneticDisordersinPregnancy249
SarahHarrisandNeetaL.Vora
Thelifeexpectancyandqualityoflifeofwomenwithgeneticdisorders continuestoimprove,resultinginmorewomenreachingreproductive ageanddesiringfertility.Itisbecomingincreasinglyimportantthatobstetriciansbecomefamiliarwithcommongeneticdisordersandtheirassociatedrisksinpregnancy.Theauthorsreviewpregnancyinwomenwith variousgeneticdisorders,includingreviewofpregnancyoutcomes,managementrecommendations,andgeneticriskassessment.Mostdataon pregnanciesinwomenwithgeneticconditionsarebasedoncasereports andliteraturereviews.Additionalstudies,includingpregnancyregistries, areneededtoimproveourunderstandingandcareofthispatient population.
MaternalCongenitalHeartDiseaseinPregnancy267
MeganE.Foeller,TimothyM.Foeller,andMauriceDruzin
Congenitalheartdiseasecomprisesmostmaternalcardiacdiseasesin pregnancyandisanimportantcauseofmaternal,fetal,andneonatal morbidityandmortalityworldwide.Pregnancyisoftenconsideredahighriskstateforindividualswithstructuralheartdiseaseasaconsequenceof alimitedabilitytoadapttothemajorhemodynamicchangesassociated withpregnancy.Preconceptioncounselingandevaluationareofutmost importance,aspregnancyiscontraindicatedincertaincardiacconditions. Pregnancycanbesafelyaccomplishedinmostindividualswithcareful riskassessmentbeforeconceptionandmultidisciplinarycarethroughout pregnancyandthepostpartumperiod.
NewInsightsinPeripartumCardiomyopathy281
MeredithO.Cruz,JoanBriller,andJudithU.Hibbard
Significantprogressinunderstandingthepathophysiologyofperipartum cardiomyopathy,especiallyhormonalandgeneticmechanisms,has beenmade.Specificcriteriashouldbeusedfordiagnosis,butthedisease
remainsadiagnosisofexclusion.Bothlong-termandrecurrentpregnancy prognosesdependonrecoveryofcardiacfunction.Datafromlargeregistriesandrandomizedcontrolledtrialsofevidence-basedtherapeuticshold promiseforfutureimprovedclinicaloutcomes.
GestationalDiabetes:UnderpinningPrinciples,Surveillance,andManagement299
JeffreyM.DenneyandKristenH.Quinn
Gestationaldiabetesmellitus(GDM)iscarbohydrateintoleranceresulting inhyperglycemiawithonsetduringpregnancy.Thisarticleprovides clinicianswithaworkingframeworktominimizematernalandneonatal morbidity.Landmarkhistoricalandrecentdataarereviewedandpresentedtoprovideclinicianswithaquick,easyreferenceforrecognition andmanagementofGDM.Datapresentedtieininsightswithunderlying pathophysiologicprocessesleadingtoGDM.Screeninganddiagnostic thresholdsarediscussedalongwithmanagementupondiagnosis.Good clinicalpracticeregardingscreening,diagnosis,andmanagementof GDMeffectivelyreducesriskandimprovesoutcomesofwomenandfetusesinaffectedpregnancies.
PregestationalDiabetesinPregnancy315
RonanSugrueandChloeZera
Diabetesisacommonchronicconditioninwomenofreproductiveage.Preconceptioncareiscrucialtoreducingtheriskofadversematernalandfetal outcomes,suchashypertensivedisorders,abnormalfetalgrowth,traumatic delivery,andstillbirth,associatedwithpoorglycemiccontrol.Insulinisthe preferredmedicationtooptimizeglucosecontrolinwomenwithpregestationaldiabetes.Frequentdoseadjustmentsareneededduringpregnancy toachieveglycemicgoals,andteam-basedmultidisciplinarycaremay help.Postpartumcareshouldincludelactationsupport,counselingoncontraceptiveoptions,andtransitiontoprimarycare.
HypertensiveDisordersinPregnancy333
AmeliaL.M.Sutton,LorieM.Harper,andAlanT.N.Tita
Hypertensivedisordersofpregnancyareaheterogeneousgroupofconditionsthatincludechronichypertension,gestationalhypertension,preeclampsia,andpreeclampsiasuperimposedonchronichypertension. Thesedisordersaccountforasignificantproportionofperinatalmorbidity andmortalityandnearly10%ofallmaternaldeathsintheUnitedStates. Giventhesubstantialhealthburdenofhypertensivedisordersinpregnancy,thereisincreasinginterestinoptimizingmanagementoftheseconditions.Thisarticlesummarizesthediagnosisandmanagementofeachof thedisordersinthespectrumofhypertensioninpregnancyandhighlights recentupdatesinthefield.
SeizuresinPregnancy349
KassieJ.BolligandDanielL.Jackson
Seizuresareamongthemostseriousneurologiccomplicationsencounteredinpregnancy.Thisarticleprovidesafoundationfortheinitial
diagnosis,evaluation,classification,andmanagementofseizuresduring pregnancy.
InfectionsinPregnancyandtheRoleofVaccines369
KimberlyB.Fortner,ClaudiaNieuwoudt,CallieF.Reeder,andGeetaK.Swamy
Pregnantwomenareatriskforinfectionandmayhavesignificant morbidityormortality.Influenza,pertussis,zika,andcytomegalovirusproducemildorasymptomaticillnessinthemotherbuthaveprofoundimplicationsforherfetus.Maternalimmunizationcanpreventormitigate infectionsinpregnantwomenandtheirinfants.TheAdvisoryCommittee ofImmunizationPracticesrecommends2vaccinesduringpregnancy:inactivatedinfluenza,andtetanustoxoid,reduceddiphtheriatoxoid,and acellularpertussisduringpregnancy.ThebenefitsofMMR,varicella, andothervaccinesarereviewed.Novelvaccinestudiesforuseduring pregnancyforpreventionofillnessareexplored.
ThromboprophylaxisinPregnancy389
DianaKolettisandSabrinaCraigo
Venousthromboembolismisaleadingcauseofmaternalmorbidityand mortalityworldwide.Identifyingwomenwhoareatgreatestriskforvenous thromboembolismandmanagingtheirpregnancieswithappropriate thromboprophylaxisisessentialtodecreasingthislife-threateningcondition.Thoseatgreatestriskarepatientswiththrombophilias,patients withapersonalorfamilyhistoryofvenousthromboembolism,andthose undergoingcesareandelivery.Currentinternationalguidelinesonthromboprophylaxisvaryindetails,butallstrategiesrelyonriskfactoridentificationandthromboprophylaxisforthehighest-riskpatients.Allguidelines requireclinicianstothinkcriticallyaboutindividualpatient’sriskfactors throughoutpregnancyandthepostpartumperiod.
OBSTETRICSANDGYNECOLOGYCLINICS
FORTHCOMINGISSUES
September2018
PerinatalMentalHealth
ConstanceGuilleandRogerB.Newman, Editors
December2018
ReproductiveAging
NanetteSantoroandHowardKravitz, Editors
March2019
GynecologicCancerCare
CarolynY.Muller, Editor
RECENTISSUES
March2018
ReproductiveGenetics
LorraineDugoff, Editor
December2017
ManagementofLaborandDelivery
AaronB.Caughey, Editor
September2017
EvaluationandManagementofVulvar Disease
ArunaVenkatesan, Editor
ISSUEOFRELATEDINTEREST
RheumaticDiseaseClinicsofNorthAmerica, May2017(Vol.43,No.2)
ReproductiveHealth
LisaR.SammaritanoandElizaF.Chakravarty, Editors Availableat: http://www.rheumatic.theclinics.com/
Accessyoursubscriptionat: www.theclinics.com
Preface MedicalDisordersinPregnancy
ErikaPeterson,MD JudithU.Hibbard,MD Editors
Wearebothprivilegedtohavetheopportunitytoeditthisimportantissueof Obstetrics andGynecologyClinicsofNorthAmerica onthetopicofMedicalDisordersinPregnancy.Recentmedicaladvanceshaveledwomenwithcomplexmedicalproblems tobeabletochoosepregnancyandbemanagedsuccessfullythroughanoftenchallenginggestation.However,theearlytwenty-firstcenturyhasalsoseenanunprecedentedincreaseinmaternalmortalityandmorbidityintheUnitedStates.Thismaybe duetosickerpatientsnowbeingabletoconceive,oraresultofincreasedratesof obesity,advancingmaternalage,andotherfactorsleadingtogreatermorbidityfrom pregnancy.
WehaveinvitedagroupofeminentMaternalFetalMedicinephysicianstoauthorarticlesthatarebothcuttingedgeandpertinenttochangingobstetricpractice.Theynot onlyreviewtimelydataoncomplexconditionsthathavebecomeprominentinthelast severaldecadesbutalsoaddressmorecommonmedicalcomplicationsofpregnancy.
Ourissuebeginswithanimportantarticlefocusingonmaternalmortalityinthe twenty-firstcentury,anexcellentstartingpointthatputsinperspectivehowchallengingthemanagementofpregnancyhasbecome.Thisisfollowedbyseveralarticles targetinganunderstandingofdiseasesthathaverecentlycometothefore.Managementofcancerinpregnancyisupdated,whileanotherarticlehighlightstheopioid epidemicandsupervisionofdependentwomeninpregnancy.Wethenturnourfocus toobesityinpregnancy,yetanotherproblemofepidemicproportionsforwhichallobstetriciansmustbeprepared,reviewingnotonlygeneralcomplicationsbutalsoweight andsurgicalmanagementoftheobesegravida.Thisisfollowedbyaverytimelyreview ofsleepapneainpregnancy,aproblemthathasriseninparallelwiththeobesityrate. Sleepapneaisfrequentlyoverlooked,sowearefortunatetoincludethisappraisalof diagnosisandtreatmentduringpregnancy.
Thenextseveralarticlesareallrelatedtomedicalconditionsthatdecadesagowere uncommoninpregnancy,asmanyofthesewomenwereoftennothealthyenoughto
ObstetGynecolClinNAm45(2018)xv–xvi https://doi.org/10.1016/j.ogc.2018.02.003
obgyn.theclinics.com 0889-8545/18/ª 2018PublishedbyElsevierInc.
MaternalMortalityinthe Twenty-FirstCentury
JohnA.Ozimek, DO,MS*,SarahJ.Kilpatrick, MD,PhD
KEYWORDS
Maternalmortality Severematernalmorbidity Racialdisparities
Maternalmortalityratio Pregnancy-relateddeath
KEYPOINTS
Maternalmortalityplaguesmuchoftheworld,with303,000maternaldeathsin2015.This numberrepresentsaglobalmaternalmortalityratioof216maternaldeathsper100,000 livebirths.
TheWorldHealthOrganizationhascreatedagoaltodecreasetheglobalmaternalmortalityratioto70maternaldeathsper100,000livebirthsbytheyear2030.
ThematernalmortalityratioishigherintheUnitedStatesthaninanyotherdeveloped nationandhasincreasedoverthelastseveralyears. SignificantracialdisparitiesexistintheratesofmaternalmortalityintheUnitedStates.
INTRODUCTION
Maternaldeathwasquitecommoninthenineteenthcenturywithasmanyas7deaths per100birthsinsomehospitalsintheUnitedStates.1 Bytheearlytwentiethcentury, maternalmortalitiesimprovedbutplateauedatapproximately6to9maternaldeaths per1000livebirths.2 Mostmaternaldeathsduringthistimeweresecondarytopoor obstetriceducationanddeliverypractices,andmostofthemwerepreventable.2 In the1920s,mostdeliveriesoccurredathomeunderthecareofmidwivesorgeneral practitioners.Deliveriesduringthistimewereoftenperformedwithoutfollowingprinciplesofaseptictechnique,resultingininfection,withsepsiscausing40%ofmaternal deaths.2 Thelargemajorityoftheremainingmaternaldeathsweresecondarytohemorrhageorpreeclampsia/eclampsia.2 Inthe1930s,alinkwasdemonstratedbetween poorasepticpractice,excessiveoperativedeliveries,andhighmaternalmortality. Thesedatawerepublishedinthe1933WhiteHouseConferenceonChildHealthProtection,Fetal,Newborn,andMaternalMortalityandMorbidityreport.2 Statemedical
Theauthorshavenofinancialdisclosures. DepartmentofObstetricsandGynecology,DivisionofMaternal-FetalMedicine,Cedars-Sinai MedicalCenter,8635West3rdStreet,Suite160-W,LosAngeles,CA90048,USA
*Correspondingauthor.
E-mailaddress: john.ozimek@cshs.org
ObstetGynecolClinNAm45(2018)175–186 https://doi.org/10.1016/j.ogc.2018.01.004
obgyn.theclinics.com 0889-8545/18/ª 2018ElsevierInc.Allrightsreserved.
timesgreaterthanthatoftheUnitedKingdomandmorethan2timesgreaterthanthe MMRinCanada.4,8
MATERNALMORTALITYINTHEUNITEDSTATES
TounderstandcurrentmaternalmortalitiesandtrendsintheUnitedStates,itisimportant torecognizetheterminologythatisused.Thereareseveralterms,eachwithaslightly differentdefinitionandresultantdifferentratesofmaternalmortality.Theuseofmultiple termsoftenleadstodifferingreportsofmaternalmortalityinbothpopularandscientific literature.Currentfrequentlyusedterminologyanddefinitionsincludethefollowing:
Pregnancy-RelatedDeath(CentersforDiseaseControlandPrevention[CDC]): thedeathofawomanwhilepregnantorwithin1yearofpregnancytermination, regardlessofthedurationorsiteofthepregnancy,fromanycauserelatedtoor aggravatedbythepregnancyoritsmanagement,butnotfromaccidentalorincidentalcauses.9
Pregnancy-RelatedDeath(WHO):thedeathofawomanwhilepregnantorwith 42daysofterminationofpregnancy,irrespectiveofthecauseofdeath.10
MaternalDeath(WHO):thedeathofawomanwhilepregnantorwithin42daysof terminationofpregnancy,irrespectiveofthedurationandsiteofthepregnancy oritsmanagementbutnotfromaccidentalorincidentalcauses.10
Pregnancy-RelatedMortalityRatio(CDC):anestimateofthenumberof pregnancy-relateddeathsforevery100,000livebirths.TheCDCreportsthat therewere17.3pregnancy-relateddeathsper100,000livebirthsintheUnited Statesin2014.9
MaternalMortalityRatio(WHO):thenumberofmaternaldeathsper100,000live births.10 TheWHOreportsthatthematernalmortalityratiointheUnitedStates was14deathsper100,000livebirthsin2015.4
TheMMRisthemostcommonlyusedmeasureofmaternalmortality.IntheUnited States,theMMRhadbeensteadilydecreasinguntilreachingitsnadirin1987at6.6.8 After1987,theMMRremainedfairlystableatbetween7and8maternaldeaths/ 100,000livebirthsuntil1999whentheMMRbegantosteadilyincrease,resultingin themostrecentreportof14deaths/100,000livebirthsin2015.4 Itispostulatedthat someofthereportedincreaseintheMMRintheUnitedStatesissecondarytoimprovementsinmethodsforidentificationofpregnancy-relateddeathsandchanges incodingandclassificationofmaternaldeaths.Otherfactorsthatarethoughtto contributetotheincreasingrateofmaternalmortalityincludeincreasingmaternal age,increasingmaternalbodymassindex,andincreasedincidenceofmedical comorbidities.11–13 Alargepopulation-levelanalysis,whichanalyzeddatafromthe CentersforDiseaseControlandPreventionNationalCenterforHealthStatisticsdatabase(CDCWONDER),demonstratedthattherewasasignificantcorrelationbetween mortalityandthepercentageofnon-Hispanicblackwomeninthedeliverypopulation, furtherillustratingknownracialdisparitiesinoverallmaternaloutcomesintheUnited States.14 Theinvestigatorsalsoconcludedthatcesareandeliveries,unintendedbirths, unmarriedstatus,and4orlessprenatalvisitsweresignificantlyassociatedwith increasedMMR.14
Thetop3causesofmaternalmortalityintheUnitedStateshavehistoricallybeen hemorrhage,hypertensivedisease,andthrombosis. 15 However,overtime,the contributionofthesecausestopregnancy-relateddeathdeclined,andby2010, deathssecondarytocardiovascularconditionsandinfectionincreasedwithcardiovascularconditionsrankedastheleadingcause.15 RecentdatafromtheCDC
PREVENTABILITY
Multiplestudieshavedemonstratedthatalmosthalfofpregnancy-relateddeathsin theUnitedStatesarepreventable.22,23 Inaretrospectivestudyofmaternaldeaths inNorthCarolina,108pregnancy-relateddeathswerereviewedbytheNorthCarolina Pregnancy-RelatedMortalityReviewCommittee.22 Theyfoundthat40%of pregnancy-relateddeathswerepotentiallypreventableandthatpreventabilityvaried bycause.Theyreportedthat93%ofhemorrhage-relateddeaths,60%of hypertension-relateddeaths,43%ofinfection-relateddeaths,and40%of cardiovascular-relateddeathswerepotentiallypreventable.Itwasalsosurmisedby theinvestigatorsthatimprovedqualityofmedicalcarewastheleadingfactorthat couldhaveledtoprevention.22 Otherstudieshavereportedsimilarfindingswith onestudyinMassachusettsreportingthat54%ofpregnancy-associateddeaths weredeemedpreventable.23 AlthoughtheMMRintheUnitedStatesisrising,luckily absolutenumbersremainlow,makingitdifficulttostudystrategiestopreventmortality.Paststudieshaveplacedmaternalmortalityattheendofacontinuumrangingfrom healthypregnancy,tomaternalmorbidity,toseverematernalmorbidity,to death.22,24–26 Ithasbeensuggestedthat,givenseverematernalmorbidityisafar morecommonoccurrencethanmaternaldeath,strategiesshouldbedevelopedto recognizeandpreventseverematernalmorbidity,therebyinterruptingthecontinuum leadingtoanddecreasingratesofmaternalmortality.
SEVEREMATERNALMORBIDITY
Likematernalmortality,severematernalmorbidityisincreasingintheUnited States.11,27,28 Itiscurrentlyestimatedtoaffectatleast50,000womenperyearwith anoccurrenceof0.5%to1.3%ofpregnanciesintheUnitedStates.27,28 Becauseseverematernalmorbiditylieswithinacontinuumrangingfromhealthypregnancyto death,effortstoidentifyandpreventcausesofseverematernalmorbidityarethought toultimatelydecreasemorbidityand,hence,maternalmortality.22,24–26 Nationalorganizationshaverecognizedthatseverematernalmorbidityisincreasingandhaveadvocatedforaprocessinwhichcasesofseverematernalmorbidityarereviewedata hospitallevel.29,30 Similartomaternaldeathreviewcommittees,thegoalistofind whereopportunitiesforimprovementincareofsuchpatientscouldhaveprevented morbidityfromoccurring,orprogressingtoasevereevent,hencereducingboth morbidityandmortality.
Identifyingspecificcasesofseverematernalmorbidityforreviewhasbeenchallengingbecausetheconceptisdifficultto defineinabsoluteterms.However,publishedguidelineshavebeensetforthandvalidatedtoallowforsensitivemethods toscreenforseverematernalmorbidity.30–32 Althoughseveralmethodsof screeningforseverematernalmorbidityhavebeenused,recentreportsrecommendusingthefollowing2screeningcriteria:pregnantorpostpartumpatients whohavebeenadmittedtotheintensivecareunitand/orhavereceived 4units ofpackedredbloodcellsbecauseoftheirhighsensitivityandspecificityforidentificationofcasesofseverematernalmorbidity.30–32 Definitive“gold-standard” guidelinestoselectcasesoftrueseverematernalmorbidityfromthosethat screenedpositiveforpossiblemor bidityhavealsobeenestablished. 33 These guidelinesarelistedinanextensiveanddetailedsystems-basedformattohelp providersdetermineiftruesevere maternalmorbidityhasoccurred. 33 Following identificationoftruecasesofseverematernalmorbidity,ithasbeenrecommended thatcasesinallhospitalsthatprovideobstetriccarebereviewedandpresentedto amultidisciplinarycommitteeinastandardizedfashiontoidentifywhere
Table1
Levelsofmaternalcare
BirthcenterPeripartumcareoflow-riskwomenwithuncomplicatedsingleton termpregnancieswithavertexpresentationwhoareexpectedto haveanuncomplicatedbirth
LevelI(basiccare)Careofuncomplicatedpregnancieswiththeabilitytodetect, stabilize,andinitiatemanagementofunanticipatedmaternal-fetal orneonatalproblemsthatoccuruntilthepatientcanbe transferredtoafacilityatwhichspecialtymaternalcareisavailable
LevelII(specialtycare)LevelIfacilitypluscareofappropriatehigh-riskconditions,both directlyadmittedandtransferredfromanotherfacility
LevelIII(subspecialty care)
LevelIV(regional perinatalhealth carecenters)
LevelIIfacilitypluscareofmorecomplexmaternalmedical conditions,obstetriccomplications,andfetalconditions
LevelIIIfacilitypluson-sitemedicalandsurgicalcareofthemost complexmaternalconditionsandcriticallyillpregnantwomenand fetuses
Adaptedfrom AmericanCollegeofObstetriciansandGynecologistsandSocietyforMaternal–Fetal Medicine,MenardMK,KilpatrickS,SaadeG,etal.Levelsofmaternalcare.AmJObstetGynecol 2015;212(3):259–71;withpermission.
ofneonatalcareviarisk-appropriatematernaltransportnetworks,butreviewsthatthis systemfocusesalmostentirelyontheneedsofthenewbornandnotnecessarilythe mother.Theinvestigatorshavecreated4objectivesincludingcreationofuniformdesignationsforlevelsofmaternalcareavailableatfacilities,todevelopstandardizeddefinitionsforfacilitiesthatprovideeachlevelofmaternalcare,toprovideconsistent guidelinesperlevelofmaternalcareforuseinqualityimprovementandhealthpromotion,andtofosterthedevelopmentandequitablegeographicdistributionoffullservicematernalcarefacilities.42 Throughtheseefforts,itishopedthatmaternalcare canbeimprovedandnationalratesofmorbidityandmortalityaredecreasedand broughtinlinewithotherdevelopednations.
SUMMARY
Despiteimprovementsinratesofglobalmaternalmortalityoverthelastcentury,it remainsaproblemthatcontinuestoplaguemuchoftheworld.Ratesofmaternal mortalityareincreasingintheUnitedStateswithsignificantracialdisparitiesthat disproportionatelyaffectnon-Hispanicblackwomen.UptohalfofpregnancyrelateddeathsintheUnitedStateshavebeenfoundtobepreventable. 14,21,22 There arestrategiesthathavebeenshowntoreducetheratesofseverematernal morbidityandmaternalmortalit yinregionsoftheUnitedStates. 36,38 Itisimperative thattheseeffortsareadoptedonanationalleveltodecreasetheratesofmaternal mortality.
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