Injuries During Injuries During Pregnancy:Pregnancy:

Understanding & TrackingUnderstanding & TrackingThe Hidden EpidemicThe Hidden Epidemic

A Focus on MortalityA Focus on Mortality

Advisory Committee on Infant MortalityAdvisory Committee on Infant MortalityWashington, DC – March, 2004Washington, DC – March, 2004

IntroductionIntroduction

ObjectivesObjectives1.1. Discuss the nature and importance of Discuss the nature and importance of

injuries on fetal and infant mortality.injuries on fetal and infant mortality.

2.2. Discuss the deficiencies and barriers of Discuss the deficiencies and barriers of using existing data to look at this issue.using existing data to look at this issue.

3.3. Discuss how to improve surveillance of Discuss how to improve surveillance of pregnancy-related injury and outcomes. pregnancy-related injury and outcomes.

4.4. Introduce the morbidity issuesIntroduce the morbidity issues

Fetal Outcome Reporting Age Fetal Outcome Reporting Age Severity Matrix for Maternal Severity Matrix for Maternal InjuryInjury

Maternal InjuryMaternal Injury

The basis of the threat to The basis of the threat to fetusesfetuses

Maternal Injury DeathsMaternal Injury Deaths

Maternal Injury Maternal Injury HospitalizationsHospitalizations

Maternal Injury ED Maternal Injury ED VisitsVisits

Injury PyramidInjury Pyramid

1. Unintentional Injury = 6,363 MV Traffic=

4,736

2. Malignant Neoplasms = 2,753

3. Homicide = 1,539

4. Heart Disease = 1,429

5. Suicide = 1,424

• Maternal Mortality (all ages) = ~450

Leading Causes of DeathLeading Causes of DeathU.S. Women, Ages 15-34U.S. Women, Ages 15-34

Year: 2000, Source CDC, WISQARS, PRMS

In the U.S., more pregnant In the U.S., more pregnant women die from intentional & women die from intentional & unintentional injury than allunintentional injury than all“maternal mortality” related “maternal mortality” related

conditions combined!conditions combined!

Pregnancy-associatedPregnancy-associatedInjury Hospital DischargesInjury Hospital Discharges19 States, ‘9719 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)

Fre

qu

ency

Pregnancy Assocaited Rate Pregnancy Assocaited Rate versus Rate Ratioversus 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)

Pre

gn

an

cy-a

sso

cia

ted

Rate

/100,0

00

Pers

on

Years

Absolute risk

Relative risk

Leading Causes of ED Leading Causes of ED Injury Visits – Women 17-Injury Visits – Women 17-3535

MV-Occupant

Fall

Overexertion

Struck By/Against

Unintent Cut/Pierce

Other Assault Struck By/Against

Other Bite/Sting

Source: US, 2000 – CDC WISQARS (NEISS)

Leading Cause of Serious Leading Cause of Serious Maternal InjuryMaternal Injury

Deaths = MVDeaths = MV

Hospitalizations = MVHospitalizations = MV

ED Visits = MVED Visits = MV

Biomechanical Biomechanical ConsiderationsConsiderations

UnbeltedUnbeltedVirginia Tech SimulationVirginia Tech Simulation

Biomechanical ModelBiomechanical Model

Fetal Injury DeathsFetal Injury Deaths

ICD ClassificationICD ClassificationICD-9ICD-9::

• 760.5760.5 = Fetus or newborn affected by = Fetus or newborn affected by maternal conditions classifiable to 800-maternal conditions classifiable to 800-995995

ICD-10ICD-10::

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

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

ICD Guidelines (WHO)ICD Guidelines (WHO)

““For single cause tabulation of the For single cause tabulation of the underlying cause of death,underlying cause of death,

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

the morbid condition is classifiable to the morbid condition is classifiable to Chapter XVIIChapter XVII

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

Out of Sight Out of Mind?Out of Sight Out of Mind?

Fetal Death RegistriesFetal Death Registries

• Most but not all statesMost but not all states

• Only 20 weeks are greater includedOnly 20 weeks are greater included

• ICD limitations (no mechanism ICD limitations (no mechanism codes)codes)

• Reliance on written cause narrativesReliance on written cause narratives

No response

Available

Not available

Response to FDC RequestResponse to FDC Request

• No response - 8 StatesNo response - 8 States• No response - 8 StatesNo response - 8 States

• Available - 16 states Available - 16 states (55% of U.S. population)(55% of U.S. population)• Available - 16 states Available - 16 states (55% of U.S. population)(55% of U.S. population)• Not available - 26 states + DCNot available - 26 states + DC• Not available - 26 states + DCNot available - 26 states + DC

272 certificates received

Traumatic Fetal DeathsTraumatic Fetal DeathsBy MechanismBy MechanismSelected States, 1995-1997Selected States, 1995-1997

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

Fetal Perinatal Crash Death Fetal Perinatal Crash Death Comparisons, 1998Comparisons, 1998

0 200 400 600 800

Low Estimate High Estimate

125

179

190

~700

Fetal MV Injury DeathsFetal MV Injury Deaths

• Account for more deaths Account for more deaths than several leading than several leading childhood injury causeschildhood injury causes

Neonatal Deaths Due to Neonatal Deaths Due to Maternal Injury, by Year, U.S. Maternal Injury, by Year, U.S. 1979-20001979-2000

Underlying Cause of Death: from CDC Wonder, ICD-9 760.5 and Underlying Cause of Death: from CDC Wonder, ICD-9 760.5 and P00.5P00.5

ICD-10

Total Miles (in billions) Driven Total Miles (in billions) Driven by Women of Reproductive Age, by Women of Reproductive Age, 1969 to 19901969 to 1990

0

50

100

150

200

250

300

350

400

450

1969 1975 1977 1983 1990

Bureau of Transportation Statistics, Omnibus Survey – US Department of Transportation

Neonatal Deaths Due to Neonatal Deaths Due to Maternal Injury, US, 1991 – Maternal Injury, US, 1991 – 1994, Underlying vs Multiple 1994, Underlying vs Multiple Cause of DeathCause of Death

YearYear

UnderlyinUnderlying Cause of g Cause of Death=76Death=76

0.50.5

All All Records Records

with with 760.5 in 760.5 in MCODMCOD

19941994 2323 4040

19931993 2626 4646

19921992 2020 3232

19911991 1919 3131

TOTALSTOTALS 88 88 (Mean=22)(Mean=22)

149 149 (Mean=37)(Mean=37)

Placental AbruptionPlacental Abruption

• Reported neonatal deaths related to Reported neonatal deaths related to maternal injury account for at least maternal injury account for at least 3% of all neonatal deaths associated 3% of all neonatal deaths associated with placental separation with placental separation

Morbidity IssuesMorbidity Issues

Birth Related ThreatsBirth Related Threats

• PrematurityPrematurity

• Low BirthweightLow Birthweight

• Obstetric complicationsObstetric complications– Placental injuryPlacental injury– Uterine ruptureUterine rupture– Amniotic ruptureAmniotic rupture– Trauma-related elective and Trauma-related elective and

therapeutic abortiontherapeutic abortion

Threats to the BabyThreats to the Baby• Neonatal DeathNeonatal Death

• Adverse development due to direct Adverse development due to direct and indirect neural and other organ and indirect neural and other organ damagedamage– Mental retardation?Mental retardation?– ADHD?ADHD?– Autism?Autism?– Cerebral palsy?Cerebral palsy?– Epilepsy?Epilepsy?– ??????

PubMed Keyword Listings – PubMed Keyword Listings – 1/021/02

• ““Motor vehicle & Pregnancy”Motor vehicle & Pregnancy” = = 155 155

• ““Alcohol & Pregnancy”Alcohol & Pregnancy” = = 15,06015,060

Population Based Fetal Population Based Fetal Trauma Outcome StudiesTrauma Outcome Studies

January/2002

• Outcomes at birth:Outcomes at birth:– WolfWolf ( (J TraumaJ Trauma, 1993): Non-seat-belt risk in , 1993): Non-seat-belt risk in

Wash. State. Wash. State. – HydeHyde et al ( et al (ObGynObGyn, 2003): Effect of motor , 2003): Effect of motor

vehicle crashes on birth & fetal outcomes in vehicle crashes on birth & fetal outcomes in UtahUtah

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

• Outcomes one or more years after birthOutcomes one or more years after birth

Utah Crash Linkage Utah Crash Linkage SummarySummary• ~3% of births linked to MV crash ~3% of births linked to MV crash

during pregnancyduring pregnancy• Pregnant women not wearing a Pregnant women not wearing a

seatbelt during an MVC were more seatbelt during an MVC were more likely to:likely to:– 1.3 times more likely to have low birth 1.3 times more likely to have low birth

weight babies compared to pregnant weight babies compared to pregnant women not involved in a MVCwomen not involved in a MVC

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

Maternal Outcomes (Schiff)Maternal Outcomes (Schiff)Adjusted RR*Adjusted RR*

(95% Confidence (95% Confidence Interval)Interval)

Preterm laborPreterm labor 3.43.4 (3.0-3.9) (3.0-3.9)

Placental Placental abruptionabruption

4.04.0 (3.0-5.4) (3.0-5.4)

Labor inductionLabor induction 1.11.1 (0.9-1.2) (0.9-1.2)

Cesarean Cesarean deliverydelivery

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

Infant Outcomes (Schiff)Infant Outcomes (Schiff)Adjusted RR*Adjusted RR*

(95% Confidence (95% Confidence Interval)Interval)

Preterm deliveryPreterm delivery 1.51.5 (1.2-1.8) (1.2-1.8)

Low birth weightLow birth weight 1.41.4 (1.1-1.8) (1.1-1.8)

Fetal distressFetal distress 1.41.4 (1.2-1.7) (1.2-1.7)

Fetal deathFetal death 2.92.9 (1.2-6.9) (1.2-6.9)

*Adjusted for smoking, education, PNC initiation

Fetal OutcomesFetal Outcomes

• Fetuses are at unique risk Fetuses are at unique risk for a variety of adverse for a variety of adverse outcomes from maternal outcomes from maternal injury, but research is injury, but research is needed to quantify these needed to quantify these and long term risks.and long term risks.

(Prenatal traumatic disruption)(Prenatal traumatic disruption)

SummarySummary• Injury and motor vehicle injury is a Injury and motor vehicle injury is a

surprisingly common occurrence during surprisingly common occurrence during pregnancy pregnancy

• MV trauma to pregnant women has probably MV trauma to pregnant women has probably increased substantially over last 20 yearsincreased substantially over last 20 years

• Critical gaps in reporting and surveillance of Critical gaps in reporting and surveillance of pregnancy related injury hide the problempregnancy related injury hide the problem

• Fetal injury mortality represents a large Fetal injury mortality represents a large proportion of childhood injury mortalityproportion of childhood injury mortality

• We are just beginning to understand and We are just beginning to understand and measure adverse birth outcomes due to measure adverse birth outcomes due to traumatrauma

• No one has measured the long term impact No one has measured the long term impact of non-fatal fetal injury among childrenof non-fatal fetal injury among children

General RecommendationsGeneral Recommendations

1.1. Incorporate maternal/fetal injury in national Incorporate maternal/fetal injury in national health prevention and research objectives.health prevention and research objectives.

2.2. Change ICD coding guidelines to encourage Change ICD coding guidelines to encourage coding external cause of maternal injury in coding external cause of maternal injury in vital records.vital records.

3.3. Include maternal injuries in expanded Include maternal injuries in expanded definition of maternal mortality.definition of maternal mortality.

4.4. Incorporate pregnancy status & fetal Incorporate pregnancy status & fetal outcomes in crash and other injury outcomes in crash and other injury surveillance systems.surveillance systems.

General RecommendationsGeneral Recommendations

5.5. States should continuously link birth to States should continuously link birth to hospital discharge data to create a maternal hospital discharge data to create a maternal injury surveillance system.injury surveillance system.

6.6. CDC should incorporate injury experience in CDC should incorporate injury experience in pregnancy risk assessment research (PRAMS).pregnancy risk assessment research (PRAMS).

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

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

Motor Vehicle Motor Vehicle RecommendationsRecommendations

9.9. All states should continuously link birth and crash All states should continuously link birth and crash data.data.

10.10.The FHA should add pregnancy status to driver The FHA should add pregnancy status to driver behavior surveys so maternal behaviors can be better behavior surveys so maternal behaviors can be better understood.understood.

11.11.NHTSA should mandate pregnant crash dummies tests NHTSA should mandate pregnant crash dummies tests to understand crash dynamics on women & fetuses.to understand crash dynamics on women & fetuses.

12.12.States should enhance education and primary belt States should enhance education and primary belt laws to improve the use and proper use of seat belts laws to improve the use and proper use of seat belts by pregnant women.by pregnant women.

13.13. International seat-belt exemptions for pregnant International seat-belt exemptions for pregnant women should be removed.women should be removed.

14.14.Research should explore ways to reduce maternal:Research should explore ways to reduce maternal:• DrivingDriving• Motor vehicle travelMotor vehicle travel• Crash riskCrash risk• Occupant protectionOccupant protection

ConclusionConclusion

QuestionQuestions?s?

Injury PreventionInjury PreventionBegins at Conception!Begins at Conception!

Hank Weiss, MPH, PhDAssociate ProfessorPhone: (412) 648-9290Email: hw@injurycontrol.comUniversity of PittsburghCenter for Injury Research and Control (CIRCL)

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

Contact InformationContact Information