Cardiac disease as a cause of maternal mortality in Europe

Transcription

1 Cardiac Problems in Pregnancy, Las Vegas, 2016 Risk prediction and maternal mortality Cardiac disease as a cause of maternal mortality in Europe (Els) Petronella G Pieper University Medical Centre Groningen The Netherlands No conflicts of interest

2 Death Valley, 26th febr 2016

3 UN 2000 Milennium Development Goals Fifth goal: worldwide reduction of maternal mortality of 75% from : maternal deaths (385 per births) aim for 2015: < deaths (96 per births) actual maternal mortality rate in 2015: 216 per births reduction 44% Alkema Lancet 2016

4 World Map Population per country worldmapper.org

5 Maternal Mortality Map worldmapper.org

6 Maternal Mortality rate per births in 2015 Alkema Lancet 2016

7 ROPAC registry (1321 pregnancies) Maternal mortality in women with heart disease developed countries 0.6% developing countries 3.9% p < Roos-Hesselink EHJ 2013

8 16 UK direct and indirect maternal mortality rates Rate per maternities direct and indirect 10 8 indirect 6 4 direct 2 Mid-year for each 3-year period MBRRACE Knight M dec 2015

9 2 Causes of maternal deaths UK Rate per maternities 1.5 Direct deaths Indirect deaths MBRRACE Knight M dec 2015

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12 acute unexpected

13 Rare diseases atypical presentation

14 High mortality Dissection 80% Infarction 7% Huisman PlosOne 2013 Elkayam Circ 2014

15 Other causes: Endocarditis Myocarditis Prosthetic valve complications Other valvular disease Congenital heart disease Pulmonary hypertension

16 Cardiac maternal mortality in Turkey Different causes than UK / Netherlands Roos-Hesselink EHJ 2013

17 Maternal Mortality Rate per births in 2015 Turkey Maternal Mortality Rate 19.7 Alkema Lancet 2016 Engin-Ustun J MatFet Neon Med 2012

18 Maternal mortality in Turkey More direct than indirect deaths (36.6%) main cause cardiac disease Turkey UK, Neth Cardiomyopathy, Ischemic heart disease, 25% 53% Dissection Valvular disease 26% 4% Engin-Ustun J MatFet Neon Med 2012

19 Maternal mortality in Turkey More direct than indirect deaths (36.6%) main cause cardiac disease Turkey UK, Neth Cardiomyopathy, Ischemic heart disease, 25% 53% Dissection Valvular disease 26% 4% mainly rheumatic heart disease Engin-Ustun J MatFet Neon Med 2012

20 Maternal mortality in Turkey More direct than indirect deaths (36.6%) main cause cardiac disease Turkey UK, Neth Cardiomyopathy, Ischemic heart disease, 25% 53% Dissection Valvular disease 26% 4% mainly rheumatic heart disease mainly prosth. valve thrombosis Engin-Ustun J MatFet Neon Med 2012

21 Can maternal mortality in Europe be further reduced? Both UK, Turkey, Netherlands: High maternal age, risk factors (obesity, smoking, hypertension)

22 UK: Indirect deaths (including cardiac causes) 50% BMI > 25 Can maternal mortality in Europe of which 2/3 obese) be further reduced? Both UK, Turkey, Netherlands: High maternal age, risk factors (obesity, smoking, hypertension) UK: Indirect deaths: 29% obese, 21% overweight Obesity: risk of acute manifestations of cardiac disease in previously healthy women (i.e. myocardial infarction) increases risk of complications in women with pre-existing heart disease (hypertension, pre-eclampsia, hemorrhage, thrombo-embolic complications, infections)

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24 Recommended weight gain Nat. Institute of Health, ESC guidelines BMI recommended weight gain < kg kg > 30 7 kg

25 Can maternal mortality in Europe be further reduced? Substandard care UK Netherlands: 28% Turkey: no data MBRRACE Knight M dec 2015

26 Can maternal mortality in Europe be further reduced? Substandard care: Failure to consider infarction or dissection in women with chest pain Failure to diagnose pulmonary edema or delay in diagnosis No preconception counseling Inappropriate management of anticoagulation therapy Inadequate communication between medical staff Saving mothers lives 2011

27 Reduce maternal mortality: multiple strategies Acute heart disease in previously healthy pregnant women is often not recognized: education of obstetricians and midwives Reduce risk factors (smoking and obesity) in all women who pursue pregnancy and in women with pre-existing heart disease Pre-conception counselling for all women with heart disease Screening of women with family history of CM or SD Well organized multidisciplinary care (communication, management protocols) Not only review mortality but also severe morbidity Saving mothers lives 2011

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29 Can maternal mortality in Europe be further reduced? Annual reduction of 1% in governmental health care spending: Increase of maternal mortality 10.6 % during that year (N=89) Increase of maternal mortality 9% in year thereafter (N=75) Multivariate analysis: increased mortality through changes in provision of skilled health professionals Study concentrated on direct deaths only Maruthappu 2014 BJOG