Hypertensive disorders of pregnancy are among the leading contributors to maternal mortality worldwide. Approximately 30,000 deaths annually are attributed to hypertensive disorders including preeclampsia, eclampsia, and HELLP syndrome.1,2 In the United States, hypertension-related disorders account for approximately 7.4% of the almost 800 pregnancy-related deaths that occur each year.3 Women with preeclampsia/eclampsia are at 3 to 25 times the risk of severe pregnancy complications including placental abruption, disseminated intravascular coagulation (DIC), renal failure, pulmonary edema and aspiration pneumonia.4,5 Recent reviews suggest that up to 60% of hypertension-related maternal deaths are potentially preventable—there continue to be missed opportunities for appropriate, recommended care of severe maternal hypertension.6 This review describes hypertension-related maternal mortality in the United States and key strategies to improve outcomes.
Recent trends in hypertension-related maternal mortality
Between 1990 and 2015, maternal mortality increased in the United States by an estimated 27% while other developed nations have experienced persistent declines.7 During that time, however, the proportion of maternal deaths attributed to hypertensive disorders declined in the United States to 7.4%, falling behind cardiovascular diseases and other medical conditions (Figure 1).3,8-10 Based upon a recent report from the Centers for Disease Control and Prevention, hypertensive disorders accounted for 6.6% of deaths during pregnancy, 9.3% of deaths within 42 days of pregnancy, and 5.4% of deaths happening between 42 days and 1 year.11
Despite the declines in hypertension-related mortality, growing numbers of women are experiencing hypertensive disorders of pregnancy due to factors including the rising obesity epidemic, delayed childbearing and the use of assisted reproductive technologies. Between 1998 and 2006, the number of obstetric hospitalizations for hypertensive disorders significantly increased from 67.2 per 1,000 deliveries to 81.4 per 1,000 deliveries, mostly related to chronic hypertension (50% increase).12 Preeclampsia/eclampsia increased from 9.4 to 12.4 per 1,000 deliveries. Severe forms of preeclampsia were associated with 38% of acute renal failure hospitalizations and 19% to 24% of hospitalizations with complications involving DIC, acute respiratory distress syndrome (ARDS), cerebrovascular accidents, and pulmonary dysfunction/edema; 14% of the hospitalizations ended in death.
State-based reviews provide greater insight into hypertension-related maternal deaths.13 In California between 2002 and 2005, women dying from preeclampsia/eclampsia were more likely to be over 30 years old (67%), delivered preterm (61%), delivered by cesarean (83%) and/or primiparous (44% vs 21% for other mortality causes). The median timing of death was within 72 hours postpartum.6
The Florida Pregnancy-Associated Mortality Review summary of preeclampsia-related deaths (1999-2012) found an elevated risk of death among women over 35, non-Hispanic black women, those with limited prenatal care (5.7 vs 1.7 pregnancy-related deaths per 100,000 live births), obese women (8.1 vs 1.1 per 100,000 live births) and those delivering preterm (47 per 100,000 if< 28 weeks, 10.2 per 100,000 if 29-36 weeks’ gestation at birth). Forty-three percent of women with hypertension-related deaths experienced cerebrovascular hemorrhage and 17% had HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome.14
The authors report no potential conflicts of interest with regard to this article.
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