Managing pregnancy-related complications: an interview with Dr. Mark Zakowski

Interview conducted by April Cashin-Garbutt, MA (Editor)Apr 2 2014

Which pregnancy-related complications are the leading causes of maternal mortality?

The leading causes of maternal mortality between 2006 and 2009 within the United States are:

• Cardiovascular diseases, 14.6%.
• Infection/sepsis, 14.0%.
• Noncardiovascular diseases, (e.g. infectious, respiratory, gastrointestinal, endocrine, hematologic), 11.9%.
• Cardiomyopathy, 11.8%.
• Hemorrhage, 11.0%.
• Hypertensive disorders of pregnancy, 9.9%.
• Thrombotic pulmonary embolism, 9.4%.
• Cerebrovascular accidents, 6.1%.
• Amniotic fluid embolism, 5.4%.
• Anesthesia complications, 0.6%.

Ref: CDC-Pregnancy Mortality Surveillance System https://www.cdc.gov/

How has pregnancy-related mortality changed over the last decade?

Pregnancy-related mortality has increased over the last 25 years.

Ten years ago the top three pregnancy-related mortality diagnoses were hemorrhage, preeclampsia, and embolism (includes thrombotic and amniotic). 

The most recent data show they have slightly been edged out by cardiovascular diseases, infection, and all non-cardiovascular disease, although they all remain close (cardiomyopathy, hemorrhage, preeclampsia) in terms of percentages.

Ref: CDC Pregnancy Morality Surveillance System

What do you think are the main reasons for the reported increase in pregnancy-related mortality?

Several reasons are possible:

• Better reporting procedures are in place.  Death certificate details have been changed to include information about pregnancy, and computerized systems of database entry offer more accurate reporting.
• The outbreak of the Swine Flu in 2009 may have increased maternal deaths reported for that flu season.
• The percentage of women having babies at an older age has increased. The birth rate of 40-44 year old women has nearly doubled, increasing from about 5.5 to over 10 births/1,000 women between 1990 and 2011 in the USA. Maternal mortality rates are significantly higher for the over 40 year old parturient – over 3 times higher than 35-39 year olds. Artificial reproductive technology helps women get pregnant at a later age and has increased the frequency of multiple births, which also carries an increased complication rate.
• The caesarean section rate has increased nearly 50%, from 24% to 33% nationally in the USA (but true generally worldwide in developed countries) over the last 10-15 years.  There is a higher maternal mortality rate associated with caesareans then vaginal delivery. This might be due to the actual surgical procedure (risk of bleeding, infection), or the maternal/fetal condition requiring a caesarean, or both.
• Increases in rates of obesity, hypertension and diabetes during pregnancy have occurred.
• The severity of heart disease among pregnant women has increased, due to better surgical and medical treatment earlier in life.

Who is most at risk of pregnancy-related complications and mortality?

African-American women have triple the risk of pregnancy-related death compared to non-Hispanic Caucasian women.

Additionally, women with pre-existing medical diseases have more complications and mortality – like obesity, chronic hypertension, cardiovascular disease and diabetes.

And older (for pregnancy) women have a greater risk of complications and mortality.

Why are they most at risk?

While medicine and surgery for treatment of medical conditions or correction of congenital heart problems have brought more women to childbearing age, they still have increased risks of complications and death.

Older (for pregnancy) women have an increased incidence of medical diseases that have not yet become obvious or “clinical” disease, but may become unmasked by the physiologic stresses of pregnancy and delivery.

Why African-American women have had an increased risk of complications is not entirely clear.  They have an increased incidence of severe hypertension, higher rate of obesity and lower haemoglobin levels on hospital admission, and on average are presented for prenatal care later than Caucasian women.

Some studies point to an increased mortality rate (case-fatality rate) for the same conditions as Caucasian women. 

Ref: Harper M. Ann Epidemiol 2007, Bryant AS. AJOG 2010.

What diagnostic and management challenges do physicians currently face?

The CMQCC Toolkit was designed for large and small hospitals, nurses, and physicians to help identify and provide management guidelines for women with preeclampsia.  However, the first step is recognition.  It is important to understand that not every woman with preeclampsia exhibits the full spectrum of symptoms or signs. 

The blood pressure criteria for treatment of hypertension in pregnancy have recently changed, and all health care providers need to be updated.  An emphasis on what should trigger a consultation with a Maternal Fetal Medicine specialist or a physician Anesthesiologist are emphasized, as well as possible transfer to a tertiary care center, if needed. 

How important is timing in the management of preeclampsia?

Timely diagnosis and treatment are very important in preventing morbidity or mortality from preeclampsia.  For instance, the new recommendation is to treat an elevated blood pressure (greater then 160 mmHg Systolic or 105 mmHg Diastolic) within one hour. 

Extremes of blood pressure occur more frequently just before bleeding into the brain.  Prior, the diagnosis of preeclampsia was based on two elevated blood pressures measured six hours apart. Now the blood pressure check, if elevated, should be repeated within 15 minutes to confirm.

How do you think care can be improved for pregnancy-related complications and what needs be done to lower maternal death rates?

Increased sensitivity to the diagnosis of preeclampsia not just while pregnant, but even in the days and weeks following delivery will improve recognition and prompt treatment, which should lower the complication rates. 

An emphasis has been placed on prompt (<1 hour) treatment of elevated blood pressures to try to reduce mortality from intracerebral hemorrhage. 

Establishment of guidelines such as the CMQCC Preeclampsia Toolkit will be very useful for institutions nationally and internationally to help ensure proper diagnosis, management, consultation and transfer to a higher level of maternity care. 

Physician Anesthesiologists provide acute critical care consultation and management in the pre-delivery, operative, and post-delivery time periods.

What can pregnant mothers do to help avoid complications?

Be familiar with the signs and symptoms of preeclampsia and seek medical care right away.

Signs might include severe headaches, blurry vision, difficulty breathing, rapid weight gain over a couple days (due to water retention), and elevated blood pressure.

Women with pre-existing medical problems such as diabetes, obesity, and chronic hypertension are at greater risk of developing preeclampsia and should be especially vigilant in monitoring their condition.

What do you think the future holds for managing pregnancy-related complications?

With more rapid diagnosis and management, the morbidity and mortality of pregnancy-related complications should decrease. The increased use of interdisciplinary teams and planning between obstetricians, physician Anesthesiologists and nurses helps to coordinate care and improve outcomes.

There are tests being developed to try to predict who is at risk and may develop preeclampsia before it becomes clinically apparent.  Being in great shape physically and nutritionally may help avoid pregnancy related complications and speed recovery. 

Where can readers find more information?

California Maternal Quality Care Collaborative Preeclampsia Toolkit: www.cmqcc.org

Preeclampsia Foundation:  www.preeclampsia.org

American Congress of Obstetricians and Gynecologists: https://www.acog.org/

Society of Obstetric Anesthesia and Perinatology:  www.soap.org

Of course I have some great tips in my book, C-Section: How to Avoid, Prepare for and Recover from Your Cesarean.

About Dr. Mark Zakowski

Mark Zakowski, M.D. is a leading expert on cesarean sections. He has been Chief of Obstetric Anesthesiology for major American hospitals for 25 years, during which time he personally helped more than 24,000 women giving birth, and has been in charge of over 125,527 deliveries.

Dr. Zakowski is committed to helping women improve their birthing experiences with education, choice, and safety. He is a featured national and international speaker on neurologic complications, heart disease in pregnancy, and anesthesia during pregnancy, to name a few.

Dr. Zakowski advocates for women’s health within the medical community through his work on numerous committees, including having served on the Board of Directors for the California Society of Anesthesiologists, the national Society of Obstetric Anesthesiology and Perinatology and the Task Force on Preeclampsia CMQCC, developing guidelines for Preeclampsia recognition and management in order to reduce maternal deaths and neonatal morbidity.

Dr. Zakowski wrote a book for pregnant couples, C-Section: How to Avoid, Prepare for and Recover from Your Cesarean and developed the Safe Baby System for women and their babies. More information is available at www.DrMarkZakowski.com and https://www.facebook.com/DrMarkZakowski/.