Hypertension in Pregnancy

ISSN: 1064-1955 (Print) 1525-6065 (Online) Journal homepage: http://www.tandfonline.com/loi/ihip20

Cardiogenic shock in pregnancy: Analysis from the

National Inpatient Sample

Jennifer Banayan, Sarosh Rana, Ariel Mueller, Avery Tung, Hadi Ramadan,
Zoltan Arany, Junaid Nizamuddin, Victor Novack, Barbara Scavone, Samuel
M. Brown & Sajid Shahul

To cite this article: Jennifer Banayan, Sarosh Rana, Ariel Mueller, Avery Tung, Hadi Ramadan,
Zoltan Arany, Junaid Nizamuddin, Victor Novack, Barbara Scavone, Samuel M. Brown & Sajid
Shahul (2016): Cardiogenic shock in pregnancy: Analysis from the National Inpatient Sample,
Hypertension in Pregnancy, DOI: 10.1080/10641955.2016.1242606

To link to this article: http://dx.doi.org/10.1080/10641955.2016.1242606

Published online: 11 Nov 2016.

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HYPERTENSION IN PREGNANCY
http://dx.doi.org/10.1080/10641955.2016.1242606

Cardiogenic shock in pregnancy: Analysis from the National Inpatient Sample

Jennifer Banayana, Sarosh Ranab, Ariel Muellerc, Avery Tunga, Hadi Ramadanb, Zoltan Aranyd,
Junaid Nizamuddina, Victor Novackc,e, Barbara Scavonea, Samuel M. Brown f, and Sajid Shahula
a
Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, USA; bDepartment of Obstetrics and Gynecology,
University of Chicago, Chicago, Illinois, USA; cDepartment of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical
Center, Harvard Medical School, Boston, Massachusetts, USA; dDepartment of Cardiology, Perelman School of Medicine, University of
Pennsylvania, Philadelphia, Pennsylvania, USA; eClinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel; fPulmonary
and Critical Care Medicine, Intermountain Medical Center, University of Utah School of Medicine, Salt Lake City, Utah, USA

ABSTRACT ARTICLE HISTORY

Objective: Cardiogenic shock (CS) may occur during pregnancy and dramatically worsen peripar- Received 9 September 2016
tum outcomes. Methods: We analyzed the National Inpatient Sample from 2002 to 2013 to Revised 22 September 2016
describe the incidence of, risk factors for and outcomes of CS during pregnancy. Results: Of the Accepted 24 September 2016
53,794,192 hospitalizations analyzed, 2044 were complicated by CS. The mortality rate in peri- KEYWORDS
partum women with CS was 18.81% versus 0.02% without. It occurs more often during post- Cardiogenic shock;
partum (58.83%) as compared with delivery (23.47%) or antepartum (17.70%) hospitalizations. extracorporeal membrane
Factors associated with CS -related death included cardiac arrest, renal failure, and sepsis. oxygenation; incidence;
Conclusions: CS during pregnancy occurs more commonly in the postpartum period and is maternal mortality;
associated with a high mortality. pregnancy

Introduction ventricular pump failure is the most common cause of

The last century has seen a dramatic reduction in
maternal mortality worldwide (1). In the United
States, however, maternal mortality has increased
since 1990 (2). Although the proportion of maternal
deaths from causes such as hemorrhage and sepsis is
declining, a rising proportion of maternal deaths is now
attributable to cardiovascular disease (3,4). In a recent
study, cardiovascular conditions ranked first on a list of
10 categories contributing to maternal mortality (3).
The mechanisms leading to an increase in maternal
cardiovascular deaths are incompletely understood. A
rising incidence of risk factors for cardiovascular dis-
ease such as advanced maternal age, obesity, hyperten-
sion, and diabetes may be responsible (5–9). An
increase over time in the cesarean delivery rate may
also increase cardiovascular morbidity in women (10),
as may the growing number of women with congenital
heart defects who have reached childbearing age (11).
Among the most extreme of cardiovascular disease
states associated with mortality is cardiogenic shock
(CS). CS represents a reduction in cardiac output suffi-
cient to cause inadequate end-organ perfusion. In the
general population, myocardial infarction with left
CS (12). The causes and outcomes of CS in pregnancy,
however, are less well-understood. We used the
National Inpatient Sample (NIS) to describe the inci-
dence of, risk factors for, complications associated with,
and outcomes for peripartum CS.
Methods
Data source
This retrospective cohort analysis included data from the
NIS from 2002 to 2013. Because the NIS includes only
deidentified data, the Institutional Review Board at the
University of Chicago declared this study exempt from
review. The NIS is derived from billing information and
provides discharge data on approximately 8 million inpa-
tient stays in the United States. The NIS randomly samples
20% of discharges from all Health Care Utilization Project
(HCUP) hospitals and then uses stratum-specific discharge
weights provided by HCUP to produce unbiased estimates
for 95% of inpatient hospitalizations. The NIS dataset
includes demographic information, comorbidities, princi-
pal and secondary diagnostic and procedure codes, inpa-
tient mortality, and discharge disposition.

CONTACT Dr. Sajid Shahul sshahul1@dacc.uchicago.edu Department of Anesthesia and Critical Care, University of Chicago, 5841 South Maryland
Ave, MC-4028 Chicago, IL, 60637, USA.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ipho
© 2017 Taylor & Francis
2 J. BANAYAN ET AL.
The NIS dataset is validated every year both intern-
ally and externally. When compared to the Medicare
Provider Analysis and Review (MedPAR) data from the
Centers for Medicare and Medicaid Services (13), exter-
nal validation of the NIS database has been excellent.
The difference between discharge counts from the
MedPAR data and the NIS was 0.7% for patients with
heart failure and CS in the general population (13).
Study population
We identified women hospitalized during the antepar-
tum, delivery, or postpartum periods. All antepartum
maternal hospitalizations were identified using clinical
classification software categories developed by the
HCUP, which groups ICD-9 diagnoses into clinically
relevant categories (14). Maternal hospitalizations for
delivery were identified using a previously validated
method employing ICD-9 codes (15). Postpartum hos-
pitalizations were identified utilizing a previously pub-
lished algorithm using the NIS (16). Briefly, postpartum
hospitalizations were identified using the fifth digit “4”
in ICD-9 codes for primary or secondary diagnosis, an
ICD-9 code “V24,” postpartum diagnosis-related group
codes (“376” or “377” for the 2002–2007 period, “776”
or “769” for the 2008–2013 period), or all of these.
Demographic characteristics, associated comorbidities,
and complications were analyzed for each discharge.
Outcomes and covariates
The primary outcome was the presence of CS, identified by
the ICD-9 code “785.51” in the diagnoses list generated
during the hospital stay. In previous studies, this definition
had very high specificity (99.3%), moderate sensitivity
(59.8%), and a high positive (78.8%) and negative (98.1%)
predictive value for detecting CS (17). To identify factors
associated with CS during pregnancy, demographic char-
acteristics and comorbidities were compared between par-
turients who developed CS and parturients admitted to the
hospital without the diagnosis of CS as our controls. We
further determined risk factors for death among pregnant
women with CS by comparing those with CS who died to
those who did not. Covariates including age, race, primary
expected payer, admission source, hospital size (number of
beds), teaching status, patient comorbidities at baseline,
and patient complications were identified and assessed
for inclusion in the model as described below. Baseline
comorbidities were defined using the well-validated
Elixhauser index of 30 comorbid conditions including
congestive heart failure, diabetes with and without compli-
cations, and renal failure (18,19).
Statistical analysis
All analyses were performed using SAS 9.3 (SAS
Institute, Cary, NC, USA) and SUDAAN 10.0
(Research Triangle Institute, Research Triangle Park,
NC, USA) to account for the complex survey design
of the NIS. Frequencies and percentages were calcu-
lated and weighted to reflect accurate, unbiased
national estimates. Categorical variables were pre-
sented as proportions and compared between groups
using the Chi-square test. To account for in-hospital
clustering, we used generalized estimating equations
with robust variance estimates. All tests were two-
sided and p-values < 0.05 were considered statistically
significant. The primary analysis used multivariable
logistic regression to identify independent factors
associated with CS during antepartum/delivery and
postpartum hospitalizations. A third regression
model evaluated risk factors associated with in-
hospital death among pregnant patients with CS. All
covariates with p-values < 0.10 on univariate analysis
were included in the model for both primary and the
secondary analyses. Results of multivariable analyses
are reported as adjusted odds ratios (ORs) and 95%
confidence intervals (CIs).
Results
We identified 52,973,186 inpatient antepartum or deliv-
ery and 821,006 postpartum hospitalizations in the
United States during the 12-year study period. Of
these, a total of 2044 (3.8 per 100,000 hospitalizations)
were complicated by CS. CS occurred more often dur-
ing the postpartum period (58.83%), followed by deliv-
ery (23.47%) and antepartum hospitalizations (17.70%).
The number of CS cases increased during the NIS
sample period (86 in 2002 versus 280 in 2013; p <
0.001). The mortality rate in pregnant women with CS
was higher than those without CS (18.81% versus
0.02%), but did not differ between antepartum
(18.29%), delivery (18.91%), and postpartum CS hospi-
talizations (18.92%).
Demographics, clinical characteristics, and
outcomes
Patient demographic and clinical characteristics are
shown in Table 1. When compared to controls, preg-
nant women with CS were older, more likely to be
admitted to an urban teaching hospital and less likely
to have private insurance than those without CS.
Pregnant women with CS were more likely than
women without CS to have diseases unrelated to
 HYPERTENSION IN PREGNANCY 3

Table 1. Baseline and hospital characteristics of pregnant patients with and without cardiogenic shock.
Weighted N (%)
No cardiogenic shock Cardiogenic shock p-Value
Number of patients 53,792,148 2044 –
Age (years) <0.0001*
15–29 32,846,461 (61.69) 918 (45.14)
30–44 20,259,408 (38.05) 1053 (51.75)
45+ 141,250 (0.27) 63 (3.11)
Race 0.0001*
White 22,247,736 (51.49) 712 (42.98)
Black 6,302,696 (14.59) 525 (31.68)
Hispanic 10,122,596 (23.43) 224 (13.55)
Asian or Pacific Islander 2,101,624 (4.86) 68 (4.12)
Native American 327,102 (0.76) 20 (1.21)
Other 2,107,224 (4.88) 107 (6.46)
Median household income for patient’s zip code (percentile) 0.18
0–25th 13,445,104 (27.83) 637 (32.72)
26th–50th 12,140,871 (25.13) 422 (21.66)
51st–75th 11,772,022 (24.36) 497 (25.50)
76th–100th 10,958,198 (22.68) 392 (20.12)
Primary expected payer <0.0001*
Medicare 380,489 (0.71) 160 (7.91)
Medicaid 22,747,306 (42.36) 918 (45.45)
Private Insurance 27,117,373 (50.49) 785 (38.90)
Self-pay 1,895,315 (3.53) 71 (3.50)
Other 1,438,702 (2.68) 80 (3.98)
Transfer in indicator <0.0001*
Not transferred in 25,389,468 (98.75) 926 (64.12)
Transferred in from a different acute care hospital 214,767 (0.84) 480 (33.18)
Transferred in from another type of health facility 106,046 (0.41) 39 (2.70)
Admission source <0.0001*
Emergency department 2,606,179 (8.35) 251 (36.70)
Another hospital 224,107 (0.72) 198 (28.95)
Another health facility including long-term care 101,146 (0.32) 28 (4.09)
Routine, birth, and other 28,274,104 (90.58) 207 (30.27)
Hospital characteristics
Bed size <0.0001*
Small 5,902,796 (11.02) 104 (5.10)
Medium 14,143,256 (26.42) 306 (15.02)
Large 33,495,420 (62.56) 1624 (79.87)
Teaching status <0.0001*
Rural 6,103,337 (11.40) 57 (2.83)
Urban nonteaching 22,292,220 (41.64) 379 (18.61)
Urban teaching 25,145,916 (46.97) 1598 (78.56)
*Significant at p < 0.05.

pregnancy such as hypertension, congestive heart fail-
ure, acute myocardial infarction, valvular disease, or
pulmonary hypertension (Table 2). These women also
had higher rates of pathologies associated with preg-
nancy such as postpartum hemorrhage, sepsis, peripar-
tum cardiomyopathy (PPCM), and amniotic fluid
embolism (AFE) than women without CS. PPCM was
present in more than half of CS cases (56%) and
accounted for 81.85% of postpartum CS cases.
We identified a variety of interventions such as mechan-
ical ventilation, Intra-aortic balloon pump (IABP),
mechanical circulatory support, and Extracorporeal mem-
brane oxygenation (ECMO) in our cohort as seen in
Table 3. Among women with CS, the use of mechanical
circulatory support increased over the NIS sample period
(5.38% in 2002 versus 14.2% in 2013, p < 0.001; Figure 1).
The mean time from the diagnosis of CS to initiation of
mechanical circulatory support was 6 days overall and
higher during hospitalizations for delivery (10.56 days,
95% CI: 2.55–18.56) than for postpartum (4.95 days, 95%
CI: 3.37–6.53) or antepartum hospitalizations (1.13 days,
95% CI: 0.21–2.06). Overall, pregnant women who devel-
oped CS and survived to discharge received mechanical
circulatory support sooner than those who died (4.36
days, 95% CI: 2.49-6.24 versus 12.46 days, 95% CI: 4.64–
20.29; p < 0.001). In women who received early mechanical
circulatory support (defined as ≤ the 6-day mean time to
mechanical circulatory support), mortality was consider-
ably less than in women who received mechanical support
later (18.08% versus 38.11%; unadjusted OR 0.33, 95% CI:
0.13–0.86).
Multivariate analyses
The results of multivariable logistic regression for the pre-
sence of CS antepartum or at delivery are presented in
Table 4. Factors associated with CS included PPCM, AFE,
pulmonary thromboembolism, fluid and electrolyte disor-
ders, coagulopathy, valvular disease, drug abuse, peripheral
vascular disorders, uncomplicated diabetes, and hospital
4 J. BANAYAN ET AL.

Table 2. Comorbidities and complications of pregnant women with and without cardiogenic shock.
Weighted N (%)
No cardiogenic shock Cardiogenic shock p-Value
Number of patients 53,792,148 2044 –
Patient comorbidities
Hypertension 1,125,355 (2.10) 329 (16.12) <0.0001*
Congestive heart failure 61,107 (0.11) 885 (43.40) <0.0001*
Acute myocardial infarction 4525 (0.01) 266 (13.01) <0.0001*
Valvular disease 275,543 (0.51) 313 (15.36) <0.0001*
Pulmonary circulation sisorders 23,135 (0.04) 145 (7.12) <0.0001*
Peripheral vascular disorders 8997 (0.02) 39 (1.89) 0.01*
Stroke 25,402 (0.05) 49 (2.39) 0.004*
Chronic pulmonary disease 1,673,056 (3.13) 150 (7.36) 0.002*
Obesity 1,563,971 (2.92) 161 (7.89) 0.0006*
Acidosis 666,270 (1.24) 1,007 (49.41) <0.0001*
Alcohol abuse 83,672 (0.16) 19 (0.94) 0.09
Drug abuse 792,784 (1.48) 147 (7.18) <0.0001*
Depression 918,772 (1.72) 130 (6.36) 0.0002*
Diabetes without chronic complications 572,659 (1.07) 108 (5.28) 0.0003*
Diabetes with chronic complications 73,009 (0.14) 28 (1.38) 0.05
Renal failure 34,733 (0.06) 137 (6.72) <0.0001*
Liver disease 73,140 (0.14) 58 (2.86) 0.001*
Thrombophilia 578,059 (1.08) 500 (24.50) <0.0001*
Amniotic fluid embolism 2395 (0.004) 81 (3.95) <0.0001*
Peripartum cardiomyopathy 40,818 (0.08) 1,152 (56.33) <0.0001*
Eclampsia 40,595 (0.08) 13 (0.66) 0.12
Preeclampsia 2,110,399 (3.92) 127 (6.22) 0.047*
Severe preeclampsia 591,856 (1.10) 48 (2.33) 0.12
Pulmonary embolism 29,843 (0.06) 143 (7.02) <0.0001*
Ischemic stroke 3845 (0.01) 20 (0.96) 0.047*
Sepsis 11,018 (0.02) 313 (15.30) <0.0001*
Complications
Cardiac arrest 3720 (0.01) 334 (16.35) <0.0001*
Death 9530 (0.02) 384 (18.81) <0.0001*
Intrauterine fetal death 51,716 (0.10) 28 (1.38) 0.02*
*Significant at p < 0.05.

8
Number Per 100,000 Maternal

6
Admissions

0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Cardiogenic Shock Mechanical Circulatory Support

45%
40%
Mortality Rate for CS Patients

35%
30%
25%
20%
15%
10%
5%
0%
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Death

Figure 1. Cardiogenic shock, mechanical circulatory support, and outcomes over the study period.
 HYPERTENSION IN PREGNANCY 5

Table 3. Interventions.
Weighted N (%)
No cardiogenic shock Cardiogenic shock p-Value
Number of patients 53,792,148 2044 –
Treatment interventions
Mechanical ventilation 100,022 (0.19) 1180 (57.72) <0.0001
Intra-aortic balloon pump (IABP) 265 (0.0005) 275 (13.45) <0.0001
Mechanical circulatory support† 72 (0.0001) 149 (7.31) <0.0001
Extracorporeal membrane oxygenation (ECMO) 172 (0.0003) 68 (3.31) 0.002
Coronary artery stent 459 (0.001) 39 (1.89) 0.005
Thrombolysis 2,670 (0.005) 19 (0.91) 0.047
Hemodialysis 8,561 (0.02) 100 (4.88) <0.0001
Percutaneous transluminal coronary angioplasty 522 (0.001) 63 (3.06) 0.0003
*Significant at p < 0.05.
†
Mechanical circulatory support includes percutaneous, biventricular, tandem, and other ventricular assist devices.

Table 4. Multivariable model of associated factors with cardio- Table 5. Multivariable model of associated factors with cardio-
genic shock antepartum or at delivery. genic shock postpartum.
Odds ratio Odds ratio
Variables (95% confidence interval) p-Value Variables (95% confidence interval) p-Value
Peripartum cardiomyopathy 75.84 (34.93, 164.70) <0.0001* Peripartum cardiomyopathy 75.71 (44.78, 128.00) <0.0001*
Amniotic fluid embolism 65.76 (20.65, 209.37) <0.0001* Pulmonary thromboembolism 3.31 (2.20, 4.99) <0.0001*
Pulmonary thromboembolism 25.48 (15.07, 43.09) <0.0001* Acidosis 4.37 (3.13, 6.09) <0.0001*
Acidosis 20.88 (13.01, 33.50) <0.0001* Thrombophilia 5.55 (3.55, 8.67) <0.0001*
Thrombophilia 8.57 (5.16, 14.22) <0.0001* Teaching status 0.0001*
Valvular disease 9.15 (4.97, 16.83) <0.0001* Urban teaching 1.00 [Reference]
Teaching status <0.0001* Urban non-teaching 1.07 (0.41, 2.80)
Urban teaching 1.00 [Reference] Rural 2.62 (1.06, 6.50)
Urban non-teaching 1.33 (0.88, 2.01) Hypertension 0.49 (0.32, 0.75) 0.001*
Rural 3.08 (1.99, 4.78) Renal failure 2.49 (1.40, 4.43) 0.002*
Drug abuse 3.31 (1.81, 6.05) 0.0001* Hospital region 0.003*
Peripheral vascular disorders 5.72 (1.45, 22.55) 0.01* Northeast 1.00 [Reference]
Diabetes, uncomplicated 1.99 (1.02, 3.87) 0.04* Midwest 1.56 (0.78, 3.14)
Age group (years) 0.09 South 1.03 (0.62, 1.71)
45+ 1.00 [Reference] West 2.16 (1.24, 3.75)
30–44 1.39 (1.03, 1.89) Calendar year 0.004*
15–29 1.47 (0.50, 4.34) 2002 1.00 [Reference]
Race 0.09 2003 0.18 (0.02, 1.72)
White 1.00 [Reference] 2004 0.34 (0.08, 1.43)
Black 1.08 (0.70, 1.65) 2005 0.36 (0.09, 1.45)
Hispanic 0.84 (0.55, 1.28) 2006 0.29 (0.07, 1.23)
Asian/Pacific Islander 1.04 (0.51, 2.14) 2007 0.59 (0.16, 2.19)
Native American 4.10 (1.56, 10.75) 2008 0.43 (0.11, 1.69)
Other 1.23 (0.63, 2.39) 2009 0.97 (0.27, 3.52)
Obesity 0.58 (0.31, 1.11) 0.10 2010 0.86 (0.24, 3.17)
Chronic pulmonary disease 1.59 (0.89, 2.85) 0.12 2011 1.07 (0.30, 3.80)
Renal failure 2.25 (0.72, 7.03) 0.16 2012 0.55 (0.15, 2.05)
Hypertension 1.30 (0.64, 2.64) 0.47 2013 1.04 (0.30, 3.60)
Preeclampsia 1.25 (0.68, 2.32) 0.48 Race 0.01*
Primary expected payer 0.65 White 1.00 [Reference]
Private insurance 0.87 (0.39, 1.90) Black 0.98 (0.66, 1.45)
Medicaid 0.85 (0.39, 1.84) Hispanic 1.03 (0.61, 1.75)
Medicare 1.00 [Reference] Asian/Pacific Islander 1.09 (0.46, 2.60)
Self-pay 0.69 (0.26, 1.84) Other 2.74 (1.53, 4.91)
Other 1.21 (0.39, 3.77) Liver disease 3.30 (1.22, 8.90) 0.02*
Valvular disease 1.65 (0.99, 2.75) 0.06
*Significant at p < 0.05. Obesity 0.67 (0.40, 1.11) 0.12
Drug abuse 1.71 (0.85, 3.44) 0.13
Age group (years) 0.16
45+ 1.00 [Reference]
30–44 1.37 (0.97, 1.93)
teaching status (multivariable model C-statistic = 0.92). 15–29 0.93 (0.39, 2.20)
Factors associated with CS during the postpartum period Peripheral vascular disorders 2.24 (0.52, 9.60) 0.28
Diabetes, uncomplicated 1.34 (0.69, 2.60) 0.38
included PPCM, pulmonary thromboembolism, fluid and Paralysis 0.76 (0.19, 2.98) 0.69
electrolyte disorders, coagulopathy, race, liver disease, renal Chronic pulmonary disease 0.96 (0.56, 1.65) 0.88
Pulmonary circulation disorders 1.01 (0.55, 1.88) 0.97
failure, hypertension, hospital teaching status, region, and Primary expected payer 0.97
calendar year (C-statistic = 0.93; Table 5). Private insurance 0.92 (0.50, 1.69)
Medicaid 0.95 (0.52, 1.71)
A third multivariate analysis targeting independent Medicare 1.00 [Reference]
factors associated with death among pregnant patients Self-pay 0.64 (0.21, 1.92)
Other 0.88 (0.30, 2.54)
with CS (Table 6) identified cardiac arrest, renal failure,
*Significant at p < 0.05.
6 J. BANAYAN ET AL.
Table 6. Multivariable model predicting death among patients
with cardiogenic shock.
Odds ratio
(95% confidence
Variables interval) p-Value
Cardiac arrest 4.94 (2.65, 9.19) <0.0001*
Renal failure 4.00 (1.69, 9.44) 0.002*
Sepsis 2.49 (1.38, 4.46) 0.003*
Reduced time (≤6 days) to 0.33 (0.13, 0.86) 0.02*
mechanical circulatory support
Acidosis 1.27 (0.75, 2.17) 0.37
*Significant at p < 0.05.
sepsis, and an increased time to mechanical circulatory
support (C-statistic 0.74).
Discussion
Using the NIS, we describe risk factors for, use of mechan-
ical support during, and outcomes associated with CS in
pregnant women admitted to United States hospitals. Our
data expand the current literature by identifying risk factors
for CS among these women and describing the use and
possible implications of mechanical circulatory support in
peripartum CS management. Our findings suggest several
important insights into this critically ill patient population.
We found that most cases of CS in pregnancy and over 80%
of postpartum CS are associated with PPCM. Antepartum
and delivery CS are also highly associated with PPCM, but
AFE or pulmonary thromboembolism may contribute to
these patient diagnosis as well. The survival rate in pregnant
women with CS (81%) was similar to published case series
on CS in pregnancy (20).
In our cohort, renal failure was associated with mortality
among parturients with CS. This finding is not surprising as
both acute and chronic renal failure increase the overall
mortality (21,22), and renal impairment reduces survival in
heart failure patients (23). In a 2015 study of hospital
mortality after acute myocardial infarction, where many
patients met criteria for CS, renal dysfunction was an inde-
pendent risk factor for death (24).
We also found an association between sepsis and CS
among pregnant women. Parturients with CS were more
likely than those without CS to have an associated sepsis
diagnosis, and sepsis was an associated risk factor for mor-
tality. Whether this association was due to sepsis-induced
myocardial dysfunction or whether CS predisposes to sepsis
during the peripartum period is unclear. Sepsis-induced
cardiomyopathy occurs in more than 40% of septic
patients, and congestive heart failure is strongly associated
with severe sepsis in pregnancy (25,26). In our sample, the
presence of sepsis and CS doubled the odds for inpatient
mortality as compared to nonseptic patients with CS.
It is also very interesting to note that admission to rural
hospital is an independent risk factor for CS. This may be
explained by differences in expertise between rural and
urban hospitals.
Unlike renal failure and sepsis, hypertensive disease
during pregnancy was not a risk factor for death from
CS. This finding is consistent with the known mechan-
ism of death in preeclampsia in which cerebral hemor-
rhage occurs from severe hypertensive episodes (27)
rather than a progression to CS.
The increasing use of mechanical assist devices in
this patient population deserves mention. We found
that 33% of parturients with CS received mechanical
circulatory support in the form of an IABP, ventricular
assist device (VAD), or ECMO. We found a survival
rate of 83.67% for patients receiving any mechanical
circulatory support including ECMO for CS, a rate
similar to that in other published reports (20). We
also found that instituting mechanical circulatory sup-
port early after the diagnosis of CS was associated with
greater survival, and that delayed initiation of mechan-
ical circulatory support (>6 days) was an independent
risk factor for inpatient mortality. CS patients who
received a VAD had even higher rates of survival:
86.72%. Isolated case reports of successful use of VAD
technology during the antepartum period suggest that a
healthy pregnancy is possible in patients with VADs
and confirms our high survival rate (28,29).
Our study has limitations. Because the NIS derives all of
its information from administrative sources based on bill-
ing codes, some conditions may be coded incorrectly or
undercoded. In addition, despite previous use of the ICD-
9 codes to identify postpartum hospitalizations in the NIS,
the sensitivity of these codes to examine post partum
hospitalizations has moderate sensitivity (70%) but a
high positive predictive value (80%). Nevertheless, because
our cohort was identified as receiving mechanical ventila-
tion, IABP support, mechanical circulatory support, vaso-
pressors, or ECMO, we believe that most patients in our
dataset were correctly identified.
Conclusion
Although uncommon, CS during pregnancy is increas-
ing in incidence and dramatically increases mortality.
Associations with CS include both pregnancy-specific
states such as PPCM and AFE and underlying cardio-
vascular disease. Renal failure, concurrent sepsis, car-
diac arrest, and delayed mechanical circulatory support
predict mortality. Early initiation of mechanical circu-
latory support in this patient population may improve
survival rates. Further work is needed to characterize
the mechanisms contributing to CS during pregnancy
and to identify therapeutic strategies.

Declaration of Interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of the article.
Funding
This study was supported by the Foundation for Anesthesia
Research (FAER) and the Center for Anesthesia Research
Excellence (CARE) at Beth Israel Deaconess Medical Center.
ORCID
Samuel M. Brown http://orcid.org/0000-0003-1206-6261
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