Injuries During Pregnancy Tracking & Understanding the Hidden Epidemic

1. AMCHP 2005 Conference Injuries During PregnancyTracking & Understandingthe Hidden Epidemic Hank Weiss PhD, Associate Professor Center for Injury Research and Control University of Pittsburgh Hank Weiss, Center for Injury Research & Control

2. Pop Quiz • The leading cause of pregnancy-related serious injury is: • Falls? • Violence? • Motor vehicle crashes? • Poisonings? • Parachute jumps? Hank Weiss, Center for Injury Research & Control

3. Parachute Jumps? 2005 Hank Weiss, Center for Injury Research & Control

4. Headlines December 19, 2004 Hank Weiss, Center for Injury Research & Control

5. 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 Injury 61* Malignant Neoplasms 31 Suicide 28 Heart Disease 10 Homicide 10* 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 Hank Weiss, Center for Injury Research & Control

6. 2. The Role of Autopsy Bias Hank Weiss, Center for Injury Research & Control

7. Pop Quiz Answer • The leading cause of pregnancy-related serious injury is: • Motor vehicle crashes • Falls • Poisonings • Violence • Parachute jumps Hank Weiss, Center for Injury Research & Control

8. 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

9. 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. Hank Weiss, Center for Injury Research & Control

10. Maternal Injury The Basis of the Threat to Fetuses Hank Weiss, Center for Injury Research & Control

11. Maternal Injury Deaths Maternal Injury Hospitalizations Maternal Injury ED Visits Injury Severity Pyramid Hank Weiss, Center for Injury Research & Control

12. Maternal Injury Deaths Maternal Injury Hospitalizations Maternal Injury ED Visits Level of Injury Pyramid Hank Weiss, Center for Injury Research & Control

13. Lack of data • New Item on Death Certificate • Geographical Bias of Reports • Autopsy Bias of Reports Hank Weiss, Center for Injury Research & Control

14. 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) Hank Weiss, Center for Injury Research & Control

15. “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

16. 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

17. Maternal Mortality Ratio, U.S. http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/00054602.htm Hank Weiss, Center for Injury Research & Control

18. U.S. Maternal Mortality (2002) = 357 Hank Weiss, Center for Injury Research & Control

19. X=7.8% U.S. Birth Rate 7.8% pregnant X 10341 injury deaths = 806 X 9/12 = 605 Hank Weiss, Center for Injury Research & Control

20. More pregnant women die from intentional & unintentionalinjury 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

21. Maternal Injury Deaths Maternal Injury Hospitalizations Maternal Injury ED Visits Next Level of Injury Pyramid Hank Weiss, Center for Injury Research & Control

22. 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. Hank Weiss, Center for Injury Research & Control

23. Pregnancy Assocaited Rate versus Rate Ratio Hank Weiss, Center for Injury Research & Control

24. Maternal Injury Deaths Maternal Injury Hospitalizations Maternal Injury ED Visits Next Level of Injury Pyramid Hank Weiss, Center for Injury Research & Control

25. Leading Causes of ED Injury Visits – Pregnant Women, Utah (Source: Weiss, Cook, Unpublished) Hank Weiss, Center for Injury Research & Control

26. Intent of ED Injury Visits – Pregnant Women, Utah (Source: Weiss, Cook, Unpublished) Hank Weiss, Center for Injury Research & Control

27. 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

28. 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

29. Maternal and Fetal Deaths = MV Hospitalizations = MV ED Visits = MV Leading Cause of Maternal Injury Hank Weiss, Center for Injury Research & Control

30. Total Miles (in billions) Driven by Women of Reproductive Age, 1969 to 1990 Bureau of Transportation Statistics, Omnibus Survey – US Department of Transportation Hank Weiss, Center for Injury Research & Control

31. Impact on the Fetus Hank Weiss, Center for Injury Research & Control

32. 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

33. 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

34. Fetal Injury Mortality Hank Weiss, Center for Injury Research & Control

35. 760.5 = Fetus or newborn affected by maternal conditions classifiable to 800-995 ICD-9 Classification “…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) Hank Weiss, Center for Injury Research & Control

36. P00.5 = Newborn (suspected to be) affected by maternal injury P01.6 = Newborn (suspected to be) affected by maternal death (all types) ICD-10 Classification Hank Weiss, Center for Injury Research & Control

37. Out of Sight Out of Mind? Hank Weiss, Center for Injury Research & Control

38. “What Gets MeasuredGets Done” James Marks MD, MPH (Commentary on Safe Motherhood) Hank Weiss, Center for Injury Research & Control

39. 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

40. 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

41. Fetal Crash Death Comparisons, 1998 Hank Weiss, Center for Injury Research & Control

42. Morbidity:Primary and Secondary Impacts on the Baby Hank Weiss, Center for Injury Research & Control

43. 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 Hank Weiss, Center for Injury Research & Control

44. Maternal Outcomes (Schiff)Hospitalized Injury/Birth Linkage *Adjusted for smoking, education, PNC initiation Hank Weiss, Center for Injury Research & Control • Schiff et al (J Trauma, 2002) (89-97): Birth outcome after hospitalized injury in Wash. State

45. Infant Outcomes (Schiff) *Adjusted for smoking, education, PNC initiation Hank Weiss, Center for Injury Research & Control

46. 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 Hank Weiss, Center for Injury Research & Control

47. 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 Hank Weiss, Center for Injury Research & Control

48. 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

49. 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 Hank Weiss, Center for Injury Research & Control

50. 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 Hank Weiss, Center for Injury Research & Control