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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
Hank Weiss, Center for Injury Research & Control
Pop Quiz
The leading cause of pregnancy-related serious injury is:1. Falls?
2. Violence?
3. Motor vehicle crashes?
4. Poisonings?
5. Parachute jumps?
Hank Weiss, Center for Injury Research & Control
Parachute Jumps?
2005
Hank Weiss, Center for Injury Research & Control
HeadlinesDecember 19, 2004
Hank Weiss, Center for Injury Research & Control
1. The Role of Place: Leading Causes of Death, 2002, All Races, Females 15-39
District of Columbia (n=121,798)
1 HIV 27
2 Homicide 19*
3 Unintentional Injury 13*
4 Malignant Neoplasms 6
5 Heart Disease 5
Utah (n=462,282)
Unintentional Injury61*
Malignant Neoplasms 31
Suicide 28
Heart Disease 10
Homicide 10* US
Unintentional Injury 9,015*
Malignant Neoplasms 5,702
Heart Disease 2,770
Suicide 2,146
Homicide 2,011*
4.5 X
6 X0.7 X
Ratio = Unintentional/Homicide
Hank Weiss, Center for Injury Research & Control
2. The Role of Autopsy Bias
Hank Weiss, Center for Injury Research & Control
Pop Quiz Answer
The leading cause of pregnancy-related serious injury is:1. Motor vehicle crashes
2. Falls
3. Poisonings
4. Violence
5. Parachute jumps
Hank Weiss, Center for Injury Research & Control
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
Hank Weiss, Center for Injury Research & Control
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.
Hank Weiss, Center for Injury Research & Control
Maternal Injury
The Basis of the Threat to Fetuses
Hank Weiss, Center for Injury Research & Control
Maternal Injury DeathsMaternal Injury Deaths
Maternal Injury HospitalizationsMaternal Injury Hospitalizations
Maternal Injury ED VisitsMaternal Injury ED Visits
Injury Severity Pyramid
Hank Weiss, Center for Injury Research & Control
Level of Injury Pyramid
Maternal Injury Maternal Injury DeathsDeaths
Maternal Injury Hospitalizations
Maternal Injury ED Visits
Hank Weiss, Center for Injury Research & Control
Lack of data
New Item on Death Certificate Geographical Bias of Reports Autopsy Bias of Reports
Hank Weiss, Center for Injury Research & Control
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)
Hank Weiss, Center for Injury Research & Control
“About one-half of all female reproductive age deaths are due to injury and half of those are due to MV crashes”
Therefore:
Hank Weiss, Center for Injury Research & Control
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’’
Hank Weiss, Center for Injury Research & Control
Maternal Mortality Ratio, U.S.
http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/00054602.htm
Hank Weiss, Center for Injury Research & Control
U.S. Maternal Mortality (2002)
= 357
Hank Weiss, Center for Injury Research & Control
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
Per
cen
t o
f P
op
ula
tio
n
7.8% pregnant X 10341 injury deaths = 806 X 9/12 = 605
X=7.8%
Hank Weiss, Center for Injury Research & Control
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:
Hank Weiss, Center for Injury Research & Control
Next Level of Injury Pyramid
Maternal Injury Deaths
Maternal Injury Maternal Injury HospitalizationsHospitalizations
Maternal Injury ED Visits
Hank Weiss, Center for Injury Research & Control
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)
Fre
qu
ency
Hank Weiss, Center for Injury Research & Control
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)
Pre
gn
an
cy-a
sso
cia
ted
Rate
/100,0
00
Pers
on
Years
Hank Weiss, Center for Injury Research & Control
Next Level of Injury Pyramid
Maternal Injury Deaths
Maternal Injury Hospitalizations
Maternal Injury ED Maternal Injury ED VisitsVisits
Hank Weiss, Center for Injury Research & Control
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
Hank Weiss, Center for Injury Research & Control
Intent of ED Injury Visits – Pregnant Women, Utah
(Source: Weiss, Cook, Unpublished)
Hank Weiss, Center for Injury Research & Control
U.S. Births vs. ED Treated Female MV Occupant, Falls & Assault Injuries
Injury Data: 2002 CDC WISQARS (non-fatal)
Hank Weiss, Center for Injury Research & Control
U.S. Births vs. ED Treated FemaleMV Occupant, Overexertion and Unintentional Struck-by/Against Injuries
Injury Data: 2002 CDC WISQARS (non-fatal)
Hank Weiss, Center for Injury Research & Control
Leading Cause of Maternal Injury
Maternal and Fetal Maternal and Fetal Deaths = MVDeaths = MV
Hospitalizations = MVHospitalizations = MV
ED Visits = MVED Visits = MV
Hank Weiss, Center for Injury Research & Control
Total Miles (in billions) Driven by Women of Reproductive Age, 1969 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
Hank Weiss, Center for Injury Research & Control
Impact on the Fetus
Hank Weiss, Center for Injury Research & Control
Fetal & Birth Related Threats
Fetal death Prematurity Low birth weight Obstetric complications
Placental injury Uterine rupture Amniotic rupture Trauma-related elective and therapeutic
abortion
Hank Weiss, Center for Injury Research & Control
Threats to the Baby
Neonatal death Direct and indirect neural and other organ and
structural damage Mental retardation? ADHD? Autism? Cerebral palsy? Epilepsy? ???
Hank Weiss, Center for Injury Research & Control
Fetal Injury Mortality
Hank Weiss, Center for Injury Research & Control
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)
Hank Weiss, Center for Injury Research & Control
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)
Hank Weiss, Center for Injury Research & Control
Out of Sight Out of Mind?
Hank Weiss, Center for Injury Research & Control
“What Gets MeasuredGets Done”
James Marks MD, MPH(Commentary on Safe Motherhood)
Hank Weiss, Center for Injury Research & Control
Fetal Death Registries
Most but not all states Only 20 weeks are greater included ICD limitations (no mechanism codes) Reliance on written cause narratives
Hank Weiss, Center for Injury Research & Control
Traumatic Fetal DeathsBy MechanismSelected States, 1995-1997
Weiss et al , JAMA, 2001, October 17;286(15):1862-1868
Hank Weiss, Center for Injury Research & Control
Fetal Crash Death Comparisons, 1998
0 200 400 600 800
Low Estimate High Estimate
125
179
190
~700
Hank Weiss, Center for Injury Research & Control
Morbidity:Primary and Secondary Impacts on the Baby
Hank Weiss, Center for Injury Research & Control
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
Hank Weiss, Center for Injury Research & Control
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
Hank Weiss, Center for Injury Research & Control
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
Hank Weiss, Center for Injury Research & Control
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
Hank Weiss, Center for Injury Research & Control
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%
Airbag + 3-pt belt 35 (22) 51%
Airbag + 3-pt belt 45 (28) 76%
*Includes placental abruption, uterine rupture, direct fetal injury, maternal death or fetal Loss
Hank Weiss, Center for Injury Research & Control
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
Hank Weiss, Center for Injury Research & Control
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
Hank Weiss, Center for Injury Research & Control
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
Hank Weiss, Center for Injury Research & Control
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 7,7137,713
1/1000 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)
Hank Weiss, Center for Injury Research & Control
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
Hank Weiss, Center for Injury Research & Control
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.
Hank Weiss, Center for Injury Research & Control
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.
Hank Weiss, Center for Injury Research & Control
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
Hank Weiss, Center for Injury Research & Control
The Hidden Epidemic
Hank Weiss, Center for Injury Research & Control
Conclusion
QuestionQuestions?s?
Injury PreventionInjury PreventionBegins at Conception!Begins at Conception!
Hank Weiss, Center for Injury Research & Control
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 Information
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