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ORIGINAL RESEARCH |
From the 1Office of Analysis and Epidemiology, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland; 2Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia; and 3Department of Obstetrics and Gynecology, New York Medical College, New York, New York.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: We used data from the Centers for Disease Control and Prevention’s Pregnancy Mortality Surveillance System to examine singleton and multifetal pregnancy-related deaths among women with a live birth or fetal death from 1979–2000. The plurality-specific (singleton or multifetal) pregnancy-based mortality ratio was defined as the number of pregnancy-related deaths per 100,000 pregnancies with a live birth. We analyzed the risk of death due to pregnancy for singleton and multifetal pregnancies by age, race, education, marital status, and cause of death.
RESULTS: Of 4,992 pregnancy-related deaths in 1979–2000, 4.2% (209 deaths) were among women with multifetal pregnancies. The risk of pregnancy death among women with twin and higher-order pregnancies was 3.6 times that of women with singleton pregnancies (20.8 compared with 5.8). The leading causes of death were similar for women with singleton pregnancies and women with multifetal pregnancies: embolism, hypertensive complications of pregnancy, hemorrhage, and infection.
CONCLUSION: Women with multifetal pregnancies have a significantly higher risk of pregnancy-related death than their counterparts with singleton pregnancies; this holds true for all women regardless of age, race, marital status, and level of education.
LEVEL OF EVIDENCE: II-2
We used data from the Centers for Disease Control and Prevention’s (CDC) Pregnancy Mortality Surveillance System to conduct an analysis of pregnancy-related mortality associated with multifetal pregnancies resulting in a live birth or fetal death. We reviewed all reported pregnancy-related deaths in the United States for 1979–2000 to understand trends in pregnancy-related mortality associated with multifetal pregnancies, to identify risk factors for these deaths, and to calculate plurality-specific pregnancy mortality ratios.
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MATERIALS AND METHODS |
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Deaths were considered pregnancy-related if they occurred during pregnancy or within 1 year of the termination of pregnancy and resulted from complications of pregnancy itself, a chain of events initiated by pregnancy, or aggravation of an unrelated event by the physiologic effects of pregnancy.7 Information on all death certificates provided by the States was reviewed by clinically experienced epidemiologists to determine whether the death was pregnancy-related and coded for cause of death, contributing conditions of death, and outcome of the pregnancy. Deaths were classified using the system designed in collaboration with the American College of Obstetricians and Gynecologists/CDC Maternal Mortality Study Group and initiated in 1988.7,8 Surveillance was conducted retrospectively for 1979 to 1987, and prospectively each year after. Increases in overall pregnancy-related mortality since 1987 have been attributed to improved surveillance and reporting guidelines.
Based on a review of all clinical information available for each death, pregnancy-related deaths were classified into 1 of 8 cause-of-death groups: hemorrhage, infection, embolism, hypertensive disorders of pregnancy, anesthesia complications, cardiomyopathy, cerebrovascular accidents, or other medical conditions (excludes external causes such as suicide).
For this analysis, we included all identified pregnancy-related deaths with a live birth or fetal death outcome. From information available, pregnancies of the women who died were identified as either singleton or multifetal. In the absence of this information, the pregnancy was considered a singleton. Approximately 7% of deaths considered singleton did not have matched live birth or fetal death certificates, which might have provided additional information on plurality.
To assess the risk of pregnancy-related death associated with multifetal pregnancy, we used a pregnancy-based mortality ratio, defined as the ratio of the number of pregnancy-related deaths to the number of pregnancies with a live birth. Plurality-specific mortality ratios were calculated separately for singleton and multifetal pregnancies. For multifetal pregnancies the pregnancy-based mortality ratio was defined as the number of pregnancy-related deaths among women with multifetal (twin and higher-order) pregnancies per 100,000 multifetal (twin and higher-order) pregnancies with a live birth. For singleton pregnancies the pregnancy-based mortality ratio was defined as the number of pregnancy-related deaths among women with singleton pregnancies per 100,000 singleton pregnancies with a live birth.
Information on singleton and twin and higher-order live births in the United States was obtained from CDC’s National Center for Health Statistics.11 For 1979–2000, no national data system reported the number of pregnancies with a live birth outcome. Therefore, we estimated the number of pregnancies with a live birth for each year using the number of live births. To estimate the number of twin pregnancies, we divided the number of twin live births by 2, and for triplet and higher-order pregnancies we divided triplet and higher-order live births by 3. The estimated numbers of twin and triplet and higher-order pregnancies were combined to provide the number of multifetal pregnancies with a live birth. Although this method is not fully weighted to account for quadruplet and higher births, those births are very rare and would have little effect on the total. Although we recognize that some multifetal pregnancies result in an outcome that includes both (1 or more) live births and stillbirths, we believe this estimate closely approximates the number of multiple pregnancies with live births.
Because of the relatively small number of deaths among women with multifetal pregnancies, we calculated 3-year (average annual) rolling mortality ratios. The relative risk (RR) of pregnancy-related death was calculated for women with multifetal pregnancies compared with women with singleton pregnancies. Ninety-five percent confidence intervals and P values were calculated using Epi Info.12
Plurality-specific pregnancy mortality was analyzed by race, age group, education, marital status, and cause of death. Race-specific mortality was not analyzed for women classified as other than white or African American because of small numbers of pregnancy-related deaths. Numbers of deaths were also too small to analyze pregnancy-related mortality for Hispanic women. Age groups were defined as less than 20 years, 20–29 years, 30–34 years, and 35 years and older. Because of small numbers, in the analysis of results by age and race, only 2 age groups were used: younger than 30 years and 30 years and older. The analysis of education was limited to women aged 20 years or older, an age by which most women would have had the opportunity to graduate from high school. The analysis of education was further restricted to those states which reported educational level on the birth certificate (42 states and the District of Columbia in 1979, 47 states and DC in 1980–87, 46 states and the District of Columbia in 1988, 48 states and the District of Columbia in 1989–91, and all states and the District of Columbia in 1992–2000). For this analysis, women who were divorced or widowed were classified as unmarried. Ratios calculated for multifetal pregnancy-related deaths are based on relatively small numbers, and the point estimates for the stratified analysis should be interpreted with caution.
We grouped deaths into 2 periods (1979–89 and 1990–2000), by plurality, to evaluate secular trends. In particular, we wanted to identify any potential increased risk among women who were characteristic of those most likely to use fertility-enhancing therapies. This study was exempt from Institutional Review Board review because it did not involve research using living human subjects.
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RESULTS |
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The most frequent causes of pregnancy-related death among singleton and multifetal pregnancies were similar: embolism, hemorrhage, hypertensive disorders of pregnancy, and infection. However, women with multifetal pregnancies were 3 to 4 times as likely to die from these causes as women with singleton pregnancies (Table 1). The RR of pregnancy-related death among women with multifetal pregnancies compared with those with singleton pregnancies was 4.2 for embolism, 3.9 for hemorrhage, and 3.1 for hypertensive disorders. The RR was essentially the same for most causes of death during the 2 periods of the study 1979–89 and 1990–2000 (data not shown). During the 22-year study period, fewer than 5 deaths among women with multifetal pregnancies were attributed to complications of anesthesia and cerebrovascular accidents.
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The risk of death from pregnancy was higher for older women than for younger women, regardless of the plurality of the pregnancy (Table 2). However, for women aged 30 years and older, as maternal age increased, the RR of pregnancy death associated with multifetal pregnancy compared with singleton pregnancy decreased. The RR associated with multifetal pregnancy was similar for both African-American and white women. For both singleton and multifetal pregnancy-related deaths, African-American women were about 3 times as likely to die as white women. The RR for each age, race, education, and marital status category for women with multifetal pregnancies compared with women with singleton pregnancies were similar during the 2 study periods (data not shown).
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The risk of pregnancy-related death was greater among women with multifetal pregnancies compared with that of women with singleton pregnancies at every level of educational attainment (4.1, 3.6, and 3.5, respectively) (Table 2). It was also greater for both married and unmarried women with multifetal pregnancies than for their counterparts with singleton pregnancies (Table 2).
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DISCUSSION |
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The leading causes of pregnancy-related death among women with multifetal pregnancy were similar to those of women with singleton pregnancy: embolism, hemorrhage, hypertensive disorders of pregnancy, and infection. The normal physiologic changes associated with pregnancy, such as increased plasma volume, increased cardiac output, and changes in coagulation factors, are further heightened in multifetal pregnancies,6 and significantly higher rates of preeclampsia, embolism, and hemorrhage in multifetal pregnancies have been reported.5,6 Increased medical morbidity, obstetric complications, and surgical interventions have been associated with multifetal pregnancies. Women with multifetal pregnancies are nearly 6 times more likely to be hospitalized with complications, including preeclampsia, pyelonephritis, and postpartum hemorrhage.4 Risk factors associated with thromboembolism (maternal age of 35 years or older, body mass index of 25 or higher, and cesarean delivery) are more common in multifetal pregnancies.13 In addition, women with multifetal pregnancies are often placed on bed rest, and the enlarged uterus mechanically obstructs venous return, contributing to lower extremity stasis. The incidence of preeclampsia is 2.6 times higher in twin pregnancies than in singleton pregnancies.14 Further, when multifetal pregnancy is complicated by preeclampsia, it is significantly more likely to occur earlier and be more severe.14,15 These myriad exaggerated physiologic effects are reflected in the increased risk of mortality from all causes for women with multifetal pregnancies.
The limitations of this analysis should be considered. Despite improved ascertainment methods initiated over the study period, pregnancy-related mortality ratios are underestimated; up to one half of pregnancy-related deaths are not identified through routine surveillance methods.16,17 Further, matched live birth or fetal death certificates were not available for 7% of pregnancy-related deaths. Because other specific information indicative of plurality was not evident, these were classified as singleton. Misclassification of multifetal pregnancies as singleton pregnancies would underestimate the multifetal pregnancy mortality ratio and overestimate the singleton pregnancy mortality ratio. The relatively small numbers of multifetal deaths did not allow detailed stratification by more than 1 variable at a time. In addition, information for multifetal pregnancy-related deaths did not always indicate the specific plurality of multiples. Therefore, we could not determine the RR of pregnancy-related death between twin pregnancies and higher-order multifetal pregnancies. However, the risk of maternal morbidity and obstetric complications in triplet and higher-order pregnancies is greater than in twin pregnancies.4,18,19
The use of assisted reproductive technology (ART) procedures increased dramatically during the 1990s.2 Pregnancies associated with ART or ovulation-inducing drugs are more likely to result in multiple births than spontaneously conceived pregnancies. In 2000, 42% of triplet and higher-order births were a result of ART, 40% were a result of ovulation-inducing drugs, and 18% were the result of spontaneous conception.2,20 Compared with women with singleton pregnancies, women with twin and triplet pregnancies are more likely to be older, non-Hispanic white, married, and better-educated.21 Concern has been expressed that multifetal pregnancies conceived through fertility-enhancing therapies may carry higher risks for the mother than spontaneous multifetal pregnancies. Information on the use of assisted reproductive technology among the women who died was not available; therefore, we were unable to determine directly whether assisted multifetal pregnancies were at any higher risk of pregnancy-related death than naturally occurring multifetal pregnancies. However, when we stratified by age and race, we did not find an increase in the RR of pregnancy-related death for white women aged 30 years and older with multifetal pregnancies between the 1980s and the 1990s (ie, the group expected to have the greatest use of ART) (data not shown). Although the specific contribution to the risk of pregnancy-related death cannot be assessed for fertility-enhancing therapies, the marked increase in multifetal pregnancies due to these therapies contributes to the cohort of women at an elevated risk of pregnancy-related death.
The American Society for Reproductive Medicine has developed and promulgated recommendations related to the optimal number of embryo transfers based upon maternal age and the presumed cause of the infertility.22 These guidelines, along with a transition to later embryo transfer, have dramatically reduced the number of higher-order multifetal gestations in more recent years. The twin rate for ART patients increased between 1997 and 2000, reaching 444.7 per 1,000 live births in 2000, whereas the triplet and higher-order birth rate for ART patients declined substantially from 134.3 to 98.7 per 1,000 live births from 1997 to 2000.20 Now, most higher-order multifetal gestations result from superovulation or ovulation induction rather than in vitro fertilization.23 In recent years, there has been an increasing use of single embryo transfer to further control the resultant twin and higher-order multifetal gestations.24
This study provides an analysis of the pregnancy-related mortality risk associated with multifetal pregnancies based on national data. These findings identify the significantly increased risk of death for women carrying more than a single fetus irrespective of maternal age, race, marital status, or level of education. Further research into the specific factors associated with the substantially increased pregnancy-related mortality ratio for women with multifetal pregnancies is clearly indicated.
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Footnotes |
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Corresponding author: Andrea P. MacKay, MSPH, National Center for Health Statistics, 3311 Toledo Road, Room 6121, Hyattsville, MD 20782; e-mail: anm3{at}cdc.gov.
doi:10.1097/01.AOG.0000200045.91015.c6
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REFERENCES |
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2. Wright VC, Schieve LA, Reynolds MA, Jeng G. Assisted reproductive technology surveillance—United States, 2000. MMWR Surveill Summ 2003;52:1–16.[Medline]
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9. Berg C, Danel I, Atrash H, Zane S, Bartlett L. Strategies to reduce pregnancy-related deaths: from identification and review to action. Atlanta (GA): Centers for Disease Control and Prevention; 2001. p. 13–7.
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12. Epidemiology Program Office, Division of Public Health Surveillance and Informatics, Centers for Disease Control and Prevention. Epi Info, Version 3.3.2. Atlanta (GA): 2005.
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22. Practice Committee of the Society for Assisted Reproductive Technology and the American Society for Reproductive Medicine. Guidelines on the number of embryos transferred. Fertil Steril 2004;82 suppl:1–2.[Medline]
23. The Practice Committee of the American Society for Reproductive Medicine. Multiple pregnancy associated with infertility therapy. Fertil Steril 2004;82 suppl:153–7.
24. Thurin A, Hausken J, Hillensjo T, Jablonowska B, Pinborg A, Strandell A, et al. Elective single-embryo transfer versus double-embryo transfer in in vitro fertilization. N Engl J Med 2004;351:2392–402.
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