title: Pregnancy-related cardiovascular deaths in California: beyond peripartum cardiomyopathy.
abstract: OBJECTIVE
  Maternal mortality rates rose markedly from 2002 to 2006 in California, prompting an in-depth maternal mortality review in a state that comprises one twelfth of the US birth cohort. Cardiovascular disease has emerged as the leading cause of pregnancy-related death in the United States. The primary aim of this analysis was to describe the incidence and type of cardiovascular disease as a cause of pregnancy-related mortality in California. The secondary aims were to describe racial/ethnic and socioeconomic disparities, risk factors, birth outcomes, timing of death and diagnosis, and signs and symptoms of cardiovascular disease and identify contributing factors.
  
  
  METHODS
  The California Pregnancy-Associated Mortality Review retrospectively examined a case series of 64 cardiovascular pregnancy-related deaths from 2002 through 2006. Two cardiologists independently reviewed complete inpatient and outpatient medical records including laboratory, radiology, electrocardiogram, chest X-ray, echocardiograms, and autopsy findings for each cardiovascular death and classified cause of death by type of cardiovascular disease. Demographic data, racial disparities, risk factors, signs and symptoms, timing of diagnosis and death, birth outcomes, and contributing factors were analyzed using bivariate comparisons with noncardiovascular pregnancy-related deaths and population-based data.
  
  
  RESULTS
  Among 2,741,220 California women who gave birth, 864 died while pregnant or within 1 year of pregnancy; 257 of the deaths were deemed pregnancy related, and of these, 64 (25%) were attributed to cardiovascular disease. There were 42 deaths caused by cardiomyopathy, and the pregnancy-related mortality rate from cardiomyopathy was 1.54 per 100,000 births. Dilated cardiomyopathy existed in 29 cases, of which 15 met the definition of peripartum cardiomyopathy. Women with cardiovascular disease were more likely than women who died from noncardiovascular causes to be African-American (39.1% vs 16.1%; P < .01) and more likely to use illicit substances (23.7% vs 9.4%; P < .01). Thirty-seven percent were obese and 20% had a concomitant diagnosis of hypertension or preeclampsia during pregnancy. Health care decisions in the diagnosis or treatment of cardiovascular disease during and after pregnancy contributed to the fatal outcomes.
  
  
  CONCLUSIONS
  African-American race, substance use, and obesity were risk factors for pregnancy-related cardiovascular disease mortality. Chronic disease prevention and better recognition and response to cardiovascular disease during pregnancy are needed to reduce maternal mortality.
authors.affiliation: Department of Obstetrics and Gynecology, University of California, Irvine, School of Medicine, Irvine, CA.
authors.forename: Afshan B
authors.initials: AB
authors.lastname: Hameed
authors.affiliation: Maternal Child and Adolescent Health Division, California Department of Public Health, Sacramento, and the Department of Family and Community Medicine, University of California, San Francisco, School of Medicine, San Francisco, CA. Electronic address: elizabeth.lawton@cdph.ca.gov.
authors.forename: Elizabeth S
authors.initials: ES
authors.lastname: Lawton
authors.affiliation: Public Health Institute, Santa Cruz, CA.
authors.forename: Christy L
authors.initials: CL
authors.lastname: McCain
authors.affiliation: California Maternal Quality Care Collaborative, Stanford University, Palo Alto, CA.
authors.forename: Christine H
authors.initials: CH
authors.lastname: Morton
authors.affiliation: Center for Family Health, California Department of Public Health, Sacramento, CA.
authors.forename: Connie
authors.initials: C
authors.lastname: Mitchell
authors.affiliation: California Pacific Medical Center, San Francisco, and California Maternal Quality Care Collaborative, Stanford University, Palo Alto, CA.
authors.forename: Elliott K
authors.initials: EK
authors.lastname: Main
authors.affiliation: Department of Medicine, University of California, San Francisco, CA.
authors.forename: Elyse
authors.initials: E
authors.lastname: Foster
mesh_terms: D000328:Adult; D002140:California / Q000453:epidemiology; D009202:Cardiomyopathies / Q000175:diagnosis / Q000208:ethnology / Q000209:etiology / Q000401:mortality; D005260:Female; D006801:Humans; D015994:Incidence; D008428:Maternal Mortality; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000175:diagnosis / Q000208:ethnology / Q000209:etiology / Q000401:mortality*; D012189:Retrospective Studies; D012307:Risk Factors
keywords: cardiovascular disease; pregnancy-related mortality