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Objective: The objective of this study was to demonstrate the increasing importance of heart disease as a cause of pregnancy-related mortality in Hawaii and the rest of the United States., Study Design: Hawaii's Department of Public Health identified all pregnancy-associated death certificates from 1991 to 2007. Hospital records and autopsy reports were reviewed to determine whether deaths were pregnancy-related., Result: From 1991 to 2007, Hawaii registered 156 deaths occurring within 1 year of pregnancy, which represented 4.2% of the total number of women who died in the same 17 to 46 years age group and 9.0% of the total number of women who died in the same 17 to 34 years age group. The pregnancy-related mortality ratio was 22.4 and the pregnancy-associated mortality ratio was 50. The leading cause of pregnancy-associated mortality was heart disease (20.5%) followed by cancer (18.6%) and suicide/homicide (12.2%). Pregnancy-related deaths (n=70) were attributed to heart disease (45.7%) followed by sepsis (14.2%) and hemorrhage (12.9%). The new Hawaii death certificate beginning in 2006 increased the detection of both pregnancy-related and -associated deaths., Conclusion: Heart disease is the most common cause of pregnancy-related mortality in Hawaii, and with improved ascertainment, may be determined to be the most common cause of pregnancy-related mortality in the rest of the United States.