Injuries During Pregnancy Tracking

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Injuries During PregnancyTracking
Understandingthe Hidden Epidemic
AMCHP 2005 Conference

• Hank Weiss PhD, Associate Professor
• Center for Injury Research and Control
• University of Pittsburgh

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Pop Quiz

• The leading cause of pregnancy-related serious
  injury is
• Falls?
• Violence?
• Motor vehicle crashes?
• Poisonings?
• Parachute jumps?

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Parachute Jumps?
2005
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Headlines
December 19, 2004
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1. The Role of Place Leading Causes of Death,
2002, All Races, Females 15-39
Utah (n462,282) Unintentional Injury 61 Malignan
t Neoplasms 31 Suicide 28 Heart
Disease 10 Homicide 10

• District of Columbia (n121,798)
• 1 HIV 27
• 2 Homicide 19
• 3 Unintentional Injury 13
• 4 Malignant Neoplasms 6
• 5 Heart Disease 5

0.7 X
6 X
US Unintentional Injury 9,015 Malignant
Neoplasms 5,702 Heart Disease 2,770 Suicide
2,146 Homicide 2,011
Ratio Unintentional/Homicide
4.5 X
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2. The Role of Autopsy Bias
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Pop Quiz Answer

• The leading cause of pregnancy-related serious
  injury is
• Motor vehicle crashes
• Falls
• Poisonings
• Violence
• Parachute jumps

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3 days of Google News US crashpregnant

• 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
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Objectives

• Overview of Epidemiology of Maternal injury.
• Nature and importance of maternal injuries to the
  Fetus and Infant.
• Deficiencies of existing data systems.
• Focus on motor vehicle injuries.
• Discuss ways to better understand and address the
  problem.

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Maternal Injury

• The Basis of the Threat to Fetuses

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Injury Severity Pyramid
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Level of Injury Pyramid
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Lack of data

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

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

• Unintentional Injury 6,908 ? MV Traffic
  4,979
• 2. Malignant Neoplasms 2,718
• 3. Homicide 1,565
• Suicide 1,489
• Heart Disease 1,370
• Total Reproductive Age Deaths 21,267Total
  Reproductive Age Injury Deaths 10,341

Year 2002, Source CDC, WISQARS, PRMSNational
Vital Statistics Reports Volume 53, Number 5
(October 12, 2004)
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About one-half of all female reproductive age
deaths are due to injury and half of those are
due to MV crashes
Therefore
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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

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Maternal Mortality Ratio, U.S.
http//www.cdc.gov/epo/mmwr/preview/mmwrhtml/00054
602.htm
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U.S. Maternal Mortality (2002)

• 357

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U.S. Birth Rate
7.8 pregnant X 10341 injury deaths 806 X
9/12 605
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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
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Next Level of Injury Pyramid
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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.
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Pregnancy Assocaited Rate versus Rate Ratio
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Next Level of Injury Pyramid
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Leading Causes of ED Injury Visits Pregnant
Women, Utah
(Source Weiss, Cook, Unpublished)
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Intent of ED Injury Visits Pregnant Women, Utah
(Source Weiss, Cook, Unpublished)
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U.S. Births vs. ED Treated Female MV Occupant,
Falls Assault Injuries
Injury Data 2002 CDC WISQARS (non-fatal)
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U.S. Births vs. ED Treated FemaleMV Occupant,
Overexertion and Unintentional Struck-by/Against
Injuries
Injury Data 2002 CDC WISQARS (non-fatal)
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Leading Cause of Maternal Injury
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Total Miles (in billions) Driven by Women of
Reproductive Age, 1969 to 1990
Bureau of Transportation Statistics, Omnibus
Survey US Department of Transportation
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Impact on the Fetus
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Fetal Birth Related Threats

• Fetal death
• Prematurity
• Low birth weight
• Obstetric complications
• Placental injury
• Uterine rupture
• Amniotic rupture
• Trauma-related elective and therapeutic abortion

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Threats to the Baby

• Neonatal death
• Direct and indirect neural and other organ and
  structural damage
• Mental retardation?
• ADHD?
• Autism?
• Cerebral palsy?
• Epilepsy?
• ???

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Fetal Injury Mortality
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ICD-9 Classification

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

E code should be used as the primary code if,
and only if, the morbid conditionis classifiable
to Chapter XVII (injury) (Injury and Poisoning)
(WHO, 1977)
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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)

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Out of Sight Out of Mind?
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What Gets MeasuredGets Done

• James Marks MD, MPH
• (Commentary on Safe Motherhood)

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Fetal Death Registries

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

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Traumatic Fetal DeathsBy MechanismSelected
States, 1995-1997
Weiss et al , JAMA, 2001, October
17286(15)1862-1868
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Fetal Crash Death Comparisons, 1998
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MorbidityPrimary and Secondary Impacts on the
Baby
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Population Based Fetal Trauma Outcome Studies

• 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

January/2002
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Maternal Outcomes (Schiff)Hospitalized
Injury/Birth Linkage
Adjusted for smoking, education, PNC initiation

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

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Infant Outcomes (Schiff)
Adjusted for smoking, education, PNC initiation
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Biomechanical ConsiderationsVirginia Tech
SimulationsMoorcraft, Duma, et al

• Driver, no restraint, 16 22 MPH
• Driver with seatbelt, 8 34 MPH
• Driver with seatbelt airbag, 28 MPH
• Front passenger improper belt use, 22 MPH
• Front passenger proper belt use airbag, 22 MPH

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Modeled Effect of Crash Factors on Risk of Fetal
Loss
Includes placental abruption, uterine rupture,
direct fetal injury, maternal death or fetal Loss
Moorcraft et al, Am J Obstet Gynecol, 2003
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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

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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

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

Hyde et al (ObGyn, 2003) Effect of motor vehicle
crashes on birth fetal outcomes in Utah
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Comparison to Infants in Crashes
Weiss Cook, 2005, Preliminary Extrapolations to
US and Infant Comparisons
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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

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General Recommendations

• Maternal/fetal injury issues should be
  incorporated in national prevention and research
  objectives.
• ICD coding guidelines need to be changed to allow
  coding external cause of maternal injury in vital
  stats.
• Maternal injuries should be included an expanded
  definition of maternal mortality.
• Pregnancy status fetal outcomes need to be
  added to injury surveillance systems.

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General Recommendations

• States should continuously link birth to hospital
  discharge and ED data to create a pregnancy
  morbidity surveillance system.
• CDC should incorporate better injury experience
  in pregnancy risk assessment (PRAMS).
• CDC should improve maternal injury details in
  their birth defects surveillance system.
• NICHD should examine ways to study developmental
  outcomes in children exposed to in utero trauma.

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Motor Vehicle Recommendations

• States should continuously link birth and crash
  data.
• The FHA should add pregnancy status to driver
  behavior surveys.
• NHTSA should mandate pregnant crash dummies tests
  to understand crash dynamics on women fetuses.
• States should enhance education belt laws to
  improve the use proper use of seat belts by
  pregnant women.
• Research should explore ways to reduce pregnant
• Driving
• Motor vehicle travel
• Crash risk
• Occupant protection

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The Hidden Epidemic
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Conclusion
Questions?
Injury Prevention Begins at Conception!
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Contact Information
Hank Weiss, MPH, PhD Associate Professor Phone
[phone] Email hw_at_injurycontrol.comUnivers
ity of Pittsburgh Center for Injury Research and
Control (CIRCL) Links http//www.circl.pitt.edu/
home/