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Women at highest risk of heart failure within 6 weeks of delivery

Heart failure is a leading cause of maternal morbidity and death in the United States – with the rate of pregnancy-related deaths more than doubling between 1987 and 2011. Even so, much about heart failure-related hospitalisations before, during and after delivery is unknown.

A study from the University of Illinois at Chicago has found that women are at the highest risk for heart failure within the six weeks after delivery, known as the postpartum period. "This finding lends support to using delivery-related hospitalisation as a window of opportunity to identify high-risk women and develop surveillance strategies before discharge," said the study's lead author, Mulubrhan Mogos, assistant professor of nursing at UIC.

The results of the study also suggest that heart failure is a significant clinical problem among relatively young reproductive-age women, especially among women with the presence of an additional disease or condition, such as hypertension, Mogos said.

The study found that although less than 2% of all pregnancy-related hospitalisations occurred during the postpartum period, nearly 60% of pregnancy-related heart failure hospitalisations took place during the same time.

The study's findings highlight the need for close monitoring of high-risk women before they are discharged from the hospital after giving birth and through the postpartum period, according to Mogos and his colleagues. Typically, women are discharged from the hospital within two to three days after delivery and are not evaluated by their health care providers again until six weeks later.

The study analysed more than 50m pregnancy-related hospitalisations in the US from 2001 to 2011. From 2001 to 2006, there was a 7.1% increase each year in heart failure diagnoses among postpartum hospitalisations, the rates then stabilised until 2011, the final year analysed.

Heart failure rates during the antepartum period, or prior to delivery, increased by an average of 4.9% per year from 2001 to 2011, which may be attributable, at least in part, to the presence of high blood pressure, diabetes or other risk factors or conditions the women had before becoming pregnant, as well as improved testing to detect heart failure, researchers found.

The women who had a heart failure diagnosis – before and after giving birth – tended to be older and black, according to researchers. The women were from the southern US and lived in low-income household areas and engaged in risky behaviours, including using tobacco, drugs and alcohol, according to the study.

Mogos and his co-authors concluded that at-risk mothers require close observation postpartum, ideally from a multidisciplinary team that includes heart failure specialists. This attention has been linked to better outcomes and fewer readmission rates.

"Health education about expectations and their risk status during delivery-related hospitalisation may empower women to seek immediate support from their social network and healthcare provider," Mogos said.

In addition, "There is a need for increased awareness and public health measures to address risk factors and promote prevention strategies among historically disadvantaged groups," he said.

Background: Heart failure (HF) is a leading cause of maternal morbidity and mortality in the United States, but prevalence, correlates, and outcomes of HF-related hospitalization during antepartum, delivery, and postpartum periods remain unknown. The objective was to examine HF prevalence, correlates, and outcomes among pregnancy-related hospitalizations among women 13 to 49 years of age.
Methods and Results: We used the 2001 to 2011 Nationwide Inpatient Sample. Rates of HF were calculated by patient and hospital characteristics. Survey logistic regression was used to estimate adjusted odds ratios representing the association between HF and each outcome, stratified by antepartum, delivery, and postpartum periods. Joinpoint regression was used to describe temporal trends in HF and in-hospital mortality. Over 50 million pregnancy-related hospitalizations were analyzed. The overall rate of HF was 112 cases per 100 000 pregnancy-related hospitalizations. Although postpartum encounters represented only 1.5% of pregnancy-related hospitalizations, ≈60% of HF cases occurred postpartum, followed by delivery (27.3%) and antepartum (13.2%). Among postpartum hospitalizations, there was a significant 7.1% (95% confidence interval, 4.4–9.8) annual increase in HF from 2001 to 2006, followed by a steady rate through 2011. HF rates among antepartum hospitalizations increased on average 4.9% (95% confidence interval, 3.0–6.8) annually from 2001 to 2011. Women with a diagnosis of HF were more likely to experience adverse maternal outcomes, as reflected by outcome-specific adjusted odds ratios during antepartum (2.7–25), delivery (6–195), and postpartum (1.5–6.6) periods.
Conclusions: HF is associated with increased risk of maternal mortality and morbidities. During hospitalization, high-risk mothers need to be identified and surveillance programs developed before discharge.

Mulubrhan F Mogos, Mariann R Piano, Barbara L McFarlin, Jason L Salemi, Kylea L Liese, Joan E Briller

[link url=""]University of Illinois in Chicago material[/link]
[link url=""]Circulation: Heart Failure abstract[/link]

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