Injuries During Pregnancy Tracking & Understanding the Hidden Epidemic

Hank Weiss, Center for Injury Research & Control

Injuries During PregnancyInjuries During PregnancyTracking & Understandingthe Hidden Epidemic

Hank Weiss PhD, Associate ProfessorCenter for Injury Research and Control

University of Pittsburgh

AMCHP 2005 Conference


Pop Quiz

The leading cause of pregnancy-related serious injury is:1. Falls?2. Violence?3. Motor vehicle crashes?4. Poisonings?5. Parachute jumps?

http://images.google.com/imgres?imgurl=http://ci.ridgefield-park.nj.us/police/graphics/domestic.gif&imgrefurl=http://ci.ridgefield-park.nj.us/police/domestic.htm&h=284&w=220&sz=4&tbnid=c5yThWJs-OIJ:&tbnh=110&tbnw=85&start=15&prev=/images%3Fq%3Ddomestic%2Bviolence%26svnum%3D100%26hl%3Den%26lr%3D%26safe%3Doff%26rls%3DGGLD,GGLD:2003-33,GGLD:en


Parachute Jumps?

2005


HeadlinesDecember 19, 2004


1. The Role of Place: Leading Causes of Death, 2002, All Races, Females 15-39

District of Columbia (n=121,798)

1 HIV 272 Homicide 19*3 Unintentional Injury 13*4 Malignant Neoplasms 6 5 Heart Disease 5

Utah (n=462,282)

Unintentional Injury61*

Malignant Neoplasms 31Suicide 28Heart Disease 10Homicide 10*

USUnintentional Injury 9,015* Malignant Neoplasms 5,702Heart Disease 2,770Suicide 2,146Homicide 2,011*

4.5 X

6 X0.7 X

Ratio = Unintentional/Homicide


2. The Role of Autopsy Bias


Pop Quiz Answer

The leading cause of pregnancy-related serious injury is:1. Motor vehicle crashes2. Falls3. Poisonings4. Violence5. Parachute jumps


3 days of Google News [US crash|pregnant]

Man, Pregnant Woman Seriously Injured In Crash - Turn to 10.com, RI - 4 hours ago. TAUNTON, Mass. -- A man and a pregnant woman were seriously injured in a car crash in Taunton Sunday night. The car went off the ...

Mother Of Unborn Baby Killed In Crash Clings For Her Life - [WCPO, OH - 11 hours ago. ... Overnight, Tameka's aunts say doctors tried to induce Tameka's pregnancy without success -- and throughout the day, tameka's health began to fail. ...

Woman forced to have C-section after car accident - Longview Daily News, WA - Feb 12, 2005. An eight-month pregnant Auburn, Wash., woman was thrown from a pickup in a Thursday morning freeway crash, leading doctors to deliver her baby in an emergency ...

RAPOZA JURY SELECTION DELAYED UNTIL FEB. 22 - KPIX-TV 5, CA - Feb 11, 2005. ... plunge near Moss Beach on Oct. 6, 2002. The crash killed Rapoza's seven-months-pregnant wife, Raye, 34, and daughter Tehani, 4. ...

SCC Freshman Died In Crash of Pickup - Nebraska StatePaper.com, NE-Feb 11, 2005. ... Benham was ejected from the truck. Her body was found in the bed of the pickup. Benham was approximately one month into a pregnancy. ...

Neurologist: Toss lawsuit in blackout driver case - Beaver County Times, PA - Feb 11, 2005. ... sentenced to three to six years in prison for an October 2000 crash that killed Patricia Schick, 54, and Sherri Zeis, 27, who was nine weeks pregnant with her ...

Feb 11-13, 2005

http://www.turnto10.com/news/4193516/detail.html





Objectives

1. Overview of Epidemiology of Maternal injury.

2. Nature and importance of maternal injuries to the Fetus and Infant.

3. Deficiencies of existing data systems.

4. Focus on motor vehicle injuries.

5. Discuss ways to better understand and address the problem.


Maternal Injury

The Basis of the Threat to Fetuses


Maternal Injury DeathsMaternal Injury Deaths

Maternal Injury HospitalizationsMaternal Injury Hospitalizations

Maternal Injury ED VisitsMaternal Injury ED Visits

Injury Severity Pyramid


Level of Injury Pyramid

Maternal Injury Maternal Injury DeathsDeaths

Maternal Injury Hospitalizations

Maternal Injury ED Visits


Lack of data

New Item on Death Certificate Geographical Bias of Reports Autopsy Bias of Reports


1. Unintentional Injury = 6,908 MV Traffic = 4,979

2. Malignant Neoplasms = 2,718

3. Homicide = 1,5654. Suicide = 1,4895. Heart Disease = 1,370

Total Reproductive Age Deaths = 21,267Total Reproductive Age Injury Deaths = 10,341

Leading Causes of DeathU.S. All Women Ages 15-34, 2002

Year: 2002, Source CDC, WISQARS, PRMSNational Vital Statistics Reports Volume 53, Number 5 (October 12, 2004)


“About one-half of all female reproductive age deaths are due to injury and half of those are due to MV crashes”

Therefore:


Maternal deaths

Defined by the World Health Organization as ‘‘the death of a women while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes’’


Maternal Mortality Ratio, U.S.

http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/00054602.htm


U.S. Maternal Mortality (2002)

= 357


U.S. Birth Rate

0%

2%

4%

6%

8%

10%

12%

15 - 19 years 20 - 24 years 25 - 29 years 30 - 34 years 35 - 39 years

Age Group

Perc

ent o

f Pop

ulat

ion

7.8% pregnant X 10341 injury deaths = 806 X 9/12 = 605

X=7.8%


More pregnant women die from intentional & unintentional injury than all “maternal mortality” related conditions combined and motor vehicles are probably the leading cause of pregnancy-associated maternal injury death (assuming little pregnancy effect on injury risk).

Therefore:


Next Level of Injury Pyramid

Maternal Injury Deaths

Maternal Injury Maternal Injury HospitalizationsHospitalizations

Maternal Injury ED Visits


Pregnancy-associatedInjury Hospital Discharges19 States, ‘97

19 State Data, Weiss HB, Lawrence BA and Miller TR. "Pregnancy associated assault hospitalizations," Obstet Gynecol, 2002; 100(3):

773-780.

0

400

800

1,200

1,600

Leading Mechanisms (pregnancy associated)

Freq

uenc

y

http://www.injurycontrol.com/Hank/reprints/ObGyn%20Preg%20Assault.pdf


Pregnancy Assocaited Rate versus Rate Ratio

Pregnancy-Associated Rate versus Rate Ratio for Leading Hospitalized Injury MechanismsDischarges with ISS ≥ 4, 19 States, 1997

Cut/pierce

Fall

Firearm

MVT Occupant

MVT Pedestrian

Overexertion

Struck by

0

10

20

30

40

50

60

0.0 0.5 1.0 1.5 2.0

Rate Ratio (pregnant/all)

Preg

nanc

y-as

soci

ated

Rat

e/10

0,00

0 Pe

rson

Yea

rs


Next Level of Injury Pyramid

Maternal Injury Deaths

Maternal Injury Hospitalizations

Maternal Injury ED Maternal Injury ED VisitsVisits


Leading Causes of ED Injury Visits – Pregnant Women, Utah

(Source: Weiss, Cook, Unpublished)

Leading Mechanisms of Pregnancy Associited Injury ED VisitsPreliminary Utah Linkage Study Data

0% 5% 10% 15% 20% 25% 30%

MVC

Fall

Cut/Piercing

Struck/Caught

Overexertion

Other

Assault

Poisoning


Intent of ED Injury Visits – Pregnant Women, Utah

(Source: Weiss, Cook, Unpublished)


U.S. Births vs. ED Treated Female MV Occupant, Falls & Assault Injuries

Injury Data: 2002 CDC WISQARS (non-fatal)


U.S. Births vs. ED Treated FemaleMV Occupant, Overexertion and Unintentional Struck-by/Against Injuries

Injury Data: 2002 CDC WISQARS (non-fatal)


Leading Cause of Maternal Injury

Maternal and Fetal Maternal and Fetal Deaths = MVDeaths = MV

Hospitalizations = MVHospitalizations = MV

ED Visits = MVED Visits = MV


Total Miles (in billions) Driven by Women of Reproductive Age, 1969 to 1990

050

100150200250300350400450

1969 1975 1977 1983 1990Bureau of Transportation Statistics, Omnibus Survey – US

Department of Transportation


Impact on the Fetus


Fetal & Birth Related Threats

Fetal death Prematurity Low birth weight Obstetric complications

Placental injury Uterine rupture Amniotic rupture Trauma-related elective and therapeutic

abortion


Threats to the Baby Neonatal death Direct and indirect neural and other organ and

structural damage Mental retardation? ADHD? Autism? Cerebral palsy? Epilepsy? ???


Fetal Injury Mortality


ICD-9 Classification

760.5 = Fetus or newborn affected by maternal conditions classifiable to 800-995

“…“…E code should be used as the primary E code should be used as the primary code if, and only if, the morbid code if, and only if, the morbid

conditionconditionis classifiable to Chapter XVII is classifiable to Chapter XVII (injury)(injury)

(Injury and Poisoning)” (WHO, 1977)(Injury and Poisoning)” (WHO, 1977)


ICD-10 Classification

P00.5 = Newborn (suspected to be) affected by maternal injury

P01.6 = Newborn (suspected to be) affected by maternal death (all types)


Out of Sight Out of Mind?


“What Gets MeasuredGets Done”

James Marks MD, MPH(Commentary on Safe Motherhood)


Fetal Death Registries

Most but not all states Only 20 weeks are greater included ICD limitations (no mechanism codes) Reliance on written cause narratives


Traumatic Fetal DeathsBy MechanismSelected States, 1995-1997

Weiss et al , JAMA, 2001, October 17;286(15):1862-1868


Fetal Crash Death Comparisons, 1998

0 200 400 600 800

Low Estimate High Estimate

125

179

190

~700


Morbidity:Primary and Secondary Impacts on the Baby


Population Based Fetal Trauma Outcome Studies

January/2002

Trauma during pregnancy; outcomes at birth: Schiff et al (J Trauma, 2002) (89-97): Birth

outcome after hospitalized injury in Wash. State Outcomes one or more years after birth

None


Maternal Outcomes (Schiff)Hospitalized Injury/Birth Linkage

Adjusted RR*(95% Confidence Interval)

Preterm labor 3.4 (3.0-3.9)

Placental abruption 4.0 (3.0-5.4)

Labor induction 1.1 (0.9-1.2)

Cesarean delivery 1.3 (1.1-1.5)*Adjusted for smoking, education, PNC initiation

–SchiffSchiff et al (J Trauma, 2002) (89-97): Birth outcome after hospitalized injury in Wash. State et al (J Trauma, 2002) (89-97): Birth outcome after hospitalized injury in Wash. State


Infant Outcomes (Schiff)Adjusted RR*

(95% Confidence Interval)

Preterm delivery 1.5 (1.2-1.8)

Low birth weight 1.4 (1.1-1.8)

Fetal distress 1.4 (1.2-1.7)

Fetal death 2.9 (1.2-6.9)

*Adjusted for smoking, education, PNC initiation


Biomechanical ConsiderationsVirginia Tech SimulationsMoorcraft, Duma, et al

Driver, no restraint, 16 & 22 MPHDriver with seatbelt, 8 & 34 MPH

Driver with seatbelt & airbag, 28 MPHFront passenger improper belt use, 22 MPH

Front passenger proper belt use + airbag, 22 MPH


Modeled Effect of Crash Factors on Risk of Fetal Loss

Moorcraft et al, Am J Obstet Gynecol, 2003

Restraint SpeedKPH (MPH)

Risk of Adverse Outcome*

None 13 (8) 36%

None 20 (12) 54%

None 25 (16) 70%

None 35 (22) 86%

3-pt belt 13 (8) 9%

3-pt belt 25 (16) 26%

3-pt belt 35 (22) 51%

3-pt belt 45 (28) 76%

3-pt belt 55 (34) 90%

Airbag + 3-pt belt 25 (16) 26%



*Includes placental abruption, uterine rupture, direct fetal injury, maternal death or fetal Loss


Population Based Fetal MV Trauma Outcome Studies

Crashes during pregnancy and outcomes at birth: Wolf (J Trauma, 1993): Non-seat-belt risk in

Wash. State. Hyde et al (ObGyn, 2003): Effect of motor vehicle

crashes on birth & fetal outcomes in Utah Child outcomes one or more years after birth

None


Pregnancy-Related Crashes

~3% of births linked to driver MV police reported crash during pregnancy (Hyde et. al., Utah crash linkage, 2003)

Extrapolations to 4 million annual births: ≅ 160,000 pregnant crashes per year ≅7 times # of infants in crashes

HydeHyde et al (ObGyn, 2003): Effect of motor vehicle crashes on birth & fetal outcomes in Utah et al (ObGyn, 2003): Effect of motor vehicle crashes on birth & fetal outcomes in Utah


Utah Crash Linkage Birth Outcome Summary

Pregnant women not wearing a seatbelt during an MVC were more likely to: 1.3 times more likely to have low birth weight

babies compared to pregnant women not involved in a MVC

nearly three times more likely to experience fetal death compared to pregnant women with seatbelts

HydeHyde et al (ObGyn, 2003): Effect of motor vehicle crashes on birth & fetal outcomes in Utah et al (ObGyn, 2003): Effect of motor vehicle crashes on birth & fetal outcomes in Utah


Comparison to Infants in Crashes

Weiss & Cook, 2005, Preliminary Extrapolations to US and Infant Comparisons

Pregnancy related MVC Pregnancy related MVC incidents by Levelincidents by Level

Pregnancy Pregnancy Extrapolation to US Extrapolation to US based on 4 million based on 4 million

live birthslive births

Infant Infant ComparisonComparison

3/100 pregnancies in crashes3/100 pregnancies in crashes 120,778120,778 24,00024,000(95-99 NASS (95-99 NASS

data)data)

1/100 pregnancies with ED MV1/100 pregnancies with ED MV 40,25940,259 7,7137,7131/1000 pregnancies 1/1000 pregnancies hospitalized with MV (from 19 hospitalized with MV (from 19 state study)state study)

40004000 400400(95-99 NASS (95-99 NASS

data)data)

Fetal DeathsFetal Deaths ~700~700 120120(2002)(2002)


Summary Injury and motor vehicle injury is a surprisingly common

occurrence during pregnancy MV trauma to pregnant women has probably increased

substantially over last 20 years Critical gaps in reporting and surveillance of pregnancy

related injury hide the problem Fetal injury mortality represents a large proportion of

childhood injury mortality We are just beginning to understand and measure

adverse birth outcomes due to trauma


General Recommendations

1. Maternal/fetal injury issues should be incorporated in national prevention and research objectives.

2. ICD coding guidelines need to be changed to allow coding external cause of maternal injury in vital stats.

3. Maternal injuries should be included an expanded definition of maternal mortality.

4. Pregnancy status & fetal outcomes need to be added to injury surveillance systems.


General Recommendations

5. States should continuously link birth to hospital discharge and ED data to create a pregnancy morbidity surveillance system.

6. CDC should incorporate better injury experience in pregnancy risk assessment (PRAMS).

7. CDC should improve maternal injury details in their birth defects surveillance system.

8. NICHD should examine ways to study developmental outcomes in children exposed to in utero trauma.


Motor Vehicle Recommendations

9. States should continuously link birth and crash data.10. The FHA should add pregnancy status to driver

behavior surveys.11. NHTSA should mandate pregnant crash dummies

tests to understand crash dynamics on women & fetuses.

12. States should enhance education & belt laws to improve the use & proper use of seat belts by pregnant women.

13. Research should explore ways to reduce pregnant:• Driving• Motor vehicle travel• Crash risk• Occupant protection


The Hidden Epidemic


Conclusion

QuestionQuestions?s?

Injury PreventionInjury PreventionBegins at Conception!Begins at Conception!


Hank Weiss, MPH, PhDAssociate ProfessorPhone: (412) 648-9290Email: [email protected] of PittsburghCenter for Injury Research and Control (CIRCL)

Links:http://www.circl.pitt.edu/home/

Contact Information

mailto:[email protected]

http://www.circl.pitt.edu/home/

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Injuries During Pregnancy Tracking & Understanding the Hidden Epidemic

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