Maternal Mortality

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					Ob Gyne Rotation: Internship.                                      4MedStudents.com 11/5/2003
Morning Presentation: Maternal Mortality.

                                 Maternal Mortality
 Maternal and infant mortality are basic health indicators that reflect a
  nation’s health status.

 Maternal deaths are defined as those deaths that occurred during a pregnancy
  or within 42 days of the end of a pregnancy and for which the cause of death
  was listed as a complication of pregnancy, childbirth, or puerperium.

 The maternal mortality rate is the number of maternal deaths per 100,000
  live births.

 In the US, the annual maternal mortality ratio remained approx. 7.5 maternal
  deaths per 100,000 live births during 1982-1996.

 Table 1. Causes of Maternal Death in the US in 1993.

            Cause                                                      No.    %
            Abortive outcome                                           47     15.56
               Ectopic pregnancy                                       34     11.2
               Spontaneous abortion                                    4      1.3
               Induced abortion                                        4      1.3
               Others (e.g. hydatidiform mole)                         5      1.7
            Direct obstetric causes                                    241    79.8
               PIH                                                     53     17.5
               Hemorrhage                                              40     13.3
               Puerperium (incl. trauma & infection)                   101    33.4
               Other (incl. pulmonary embolus & chorioCa)              47     15.6
            Indirect obstetric causes (incl. accidents)                14     4.64
            Total Maternal Deaths                                      302    100

Modified from Monthly Vital Statistics Report, DHHS-PHS publ No. 95-1120, vol 44, pp 1-88, 1995.

 More than ½ of all maternal deaths can be prevented through early diagnosis
  and appropriate medical care of pregnancy complications. Hemorrhage,
  pregnancy-induced HTN, infection, and ectopic pregnancy continue to
  account for most (59%) maternal deaths.

 Maternal mortality ratios remained higher for black women than for white
  women.

 Maternal mortality has fallen from 70 per 100,000 in the 1950’s to 11 per
  100,000 in 1994-1996 in the UK. The main reduction has been in direct

Dr. Khalid A. Yarouf (intern).                                                        Page 1 of 9
Ob Gyne Rotation: Internship.                             4MedStudents.com 11/5/2003
Morning Presentation: Maternal Mortality.

    causes, particularly those related to abortion, following the liberalization of
    abortion laws in 1968.




 Some States in the US reestablished maternal mortality review committees to
  identify interventions that may have an impact on reducing maternal
  mortality. These committees review various factors that may have
  contributed to maternal deaths, including the quality of medical care and
  systemic problems in the health-care delivery system.

 Japan’s maternal mortality rate is higher than that of other developed
  countries.
  Japanese conducted a cross-sectional study of maternal deaths between 1991
  and 1992.
  Objectives: to identify causes of maternal mortality in Japan, examine
  attributes of treating facilities associated with maternal mortality, and assess
  the preventability of such deaths.
  Conclusion:
         o Maternal mortality was 9.5 per 100,000 births.
         o Inadequate obstetric and anesthetic services and laboratories
            facilities are associated with maternal mortality.




Dr. Khalid A. Yarouf (intern).                                            Page 2 of 9
Ob Gyne Rotation: Internship.                             4MedStudents.com 11/5/2003
Morning Presentation: Maternal Mortality.

                      Venous thromboembolic disease (TED)


 Venous thromboembolic disease (TED) occurs when a blood clot forms in a
  deep vein, usually in a leg  forming a DVT, which may cause pain &
  swelling.




 This is very rarely fatal, but if part of the clot breaks off it may be carried by
  the blood to the lungs  blocks a blood vessel there                            

    1. PULMONARY EMBOLISM (PE)  more serious, symptoms: chest
       pain, SOB, hemoptysis (coughing blood), and if large, severe hypoxia &
       collapse.

    2. Serious long-term maternal morbidity, including venous insufficiency,
       often manifests as a painful & often ulcerating leg, due to compromised
       blood flow to limb.




Dr. Khalid A. Yarouf (intern).                                            Page 3 of 9
Ob Gyne Rotation: Internship.                          4MedStudents.com 11/5/2003
Morning Presentation: Maternal Mortality.


 TED is the leading cause of maternal mortality in developed countries and
  most of the maternal deaths caused by it are due to pulmonary embolism.

 There is an increasing chance of a thromboembolic event (DVT or PE)
  occurring during pregnancy and the immediate postnatal period, because of
  chemical changes in the blood and a reduction in the velocity of blood flow
  in the lower limbs. However, the best recent estimate of TED incidence is
  from a Swedish study in 1999 which shows that it is rare during pregnancy
  & the immediate postnatal period.

 Some groups of women have a higher risk of developing TED in association
  with pregnancy. Specific risk factors that have been identified include:

            1.   Operative delivery.
            2.   Having had ≥1 previous episodes of TED.
            3.   FHx of TED.
            4.   Having inherited or acquired thrombophilia (condition that
                 predisposes people to developing thromboses).
            5.   Obesity.
            6.   Greater maternal age.
            7.   Higher parity.
            8.   Prolonged immobilization.

 The size of the increases in risk attributable to these factors are generally
  poorly quantified, e.g. for women who had previous thrombosis, the risk of
  TED has been estimated as  2.4% if antenatal thromboprophylaxis is not
  used (95% confidence interval 0.2 – 6.9%).




Dr. Khalid A. Yarouf (intern).                                         Page 4 of 9
Ob Gyne Rotation: Internship.                          4MedStudents.com 11/5/2003
Morning Presentation: Maternal Mortality.

                                  Pulmonary Embolism

 The mortality and morbidity rates from venous thromboembolism are best
  described in 2 words: substantial and unacceptable !

 Clinical features:
  o Presentation may vary from a sudden onset of catastrophic hemodynamic
     collapse to gradually progressive dyspnea. The diagnosis of PE should be
     sought actively in patients with respiratory symptoms unexplained by an
     alternate diagnosis. The symptoms of PE are nonspecific; therefore, a
     high index of suspicion is required, particularly when a patient has risk
     factors, which include recent surgery, immobility, or a hypercoagulable
     state.

    o The most common symptoms of PE in the Prospective Investigation of
      Pulmonary Embolism Diagnosis (PIOPED) study were dyspnea (73%),
      pleuritic chest pain (66%), cough (37%), and hemoptysis (13%).

    o The most common physical signs in the PIOPED study were as follows:
      tachypnea (70%), rales (51%), tachycardia (30%), fourth heart sound
      (24%), and accentuated pulmonic component of the second heart sound
      (23%).

 Massive PE:
  o Large emboli compromise sufficient pulmonary circulation  circulatory
    collapse and shock.
  o The patient has hypotension; appears weak, pale, sweaty, and oliguric;
    and develops impaired mentation.

 Investigations:

    o Arterial blood gases (ABG)  characteristically reveal hypoxemia,
      hypocapnia, and respiratory alkalosis.

    o Imaging studies:
       Chest radiograph: Initially, the chest radiography findings commonly
        are normal. However, in later stages, the x-ray film may show
        radiographic signs that include a Westermark sign (dilatation of
        pulmonary vessels and a sharp cutoff), atelectasis, a small pleural
        effusion, and an elevated diaphragm.




Dr. Khalid A. Yarouf (intern).                                         Page 5 of 9
Ob Gyne Rotation: Internship.                               4MedStudents.com 11/5/2003
Morning Presentation: Maternal Mortality.




         Ventilation-perfusion (V/Q) scanning of the lungs: for establishing
          the diagnosis of PE.




         Color-flow Doppler imaging and compression US: have ↑ sensitivity
          & specificity.

         Pulmonary angiography:            remains the criterion standard for the
          diagnosis of PE.

         MRI: 85% sensitive, 96% specific for central, lobar, and segmental
          emboli; MRI is inadequate for the diagnosis of subsegmental emboli.




Dr. Khalid A. Yarouf (intern).                                              Page 6 of 9
Ob Gyne Rotation: Internship.                          4MedStudents.com 11/5/2003
Morning Presentation: Maternal Mortality.

    o ECG:
       Commonest abnormalities of PE are tachycardia and nonspecific ST-T
        wave abnormalities. These findings are not sensitive or specific
        enough to aid in Dx of PE.

         The classic finding of right-heart strain demonstrated by an S1-Q3-T3
          pattern is observed in only 20% of patients with proven PE.




 Mx:
  o Immediate full anticoagulation is mandatory for all patients suspected to
    have DVT or PE.

 Prognosis:
  o Death from a massive PE is second only to the sudden cardiac death.
     Autopsy studies of hospitalized patients have shown approx. 80% of
     these patients died from massive PE.

    o Approx. 10% of patients who develop PE die within the first hour, and
      30% die subsequently from recurrent embolism.




Dr. Khalid A. Yarouf (intern).                                         Page 7 of 9
Ob Gyne Rotation: Internship.                                   4MedStudents.com 11/5/2003
Morning Presentation: Maternal Mortality.

         Thromboprophylaxis during antenatal and postnatal period

 Women who have particular risk factors for the development of TED are often
    given thromboprophylaxis during the antenatal or postnatal period or both.
    Pharmacological and non-pharmacological methods have been used.

    o Pharmacological methods:
            Use anti-coagualnts  help prevent blood clotting.
            Include: Heparin, warfarin, aspirin, hydroxyethyl starch.
    o Non-pharmacological methods:
            Keep blood moving in lower limbs  help prevent clot formation.
            Include: stockings, pneumatic compression, early mobilization and
              surveillance.

 The duration of prophylaxis varies depending on the risk factor. Women who have
    had a previous episode of TED may receive long-term antenatal prophylaxis as
    well as prolonged postnatal prophylaxis, while women undergoing delivery by C-
    section may receive only postnatal prophylaxis for a few days.

 All the current guidelines mentioned above are based on expert opinion only,
    rather than high quality evidence from randomized trials.

 Cochrane Reviewers searched for randomized Controlled Trials (RCTs)
    concerning this issue to determine the effects of thromboprophylaxis in association
    with pregnancy in women who are pregnant or have recently delivered on the
    incidence of venous thromboembolic disease and side effects.

 Recent Cochrane Review shows that the evidence available from RCTs is clearly
    inadequate as a basis for clinical decisions. Guidelines for thromboprophylaxis in
    pregnancy and the postnatal period have been produced by the Royal College of
    Obstetricians and Gynaecologists (RCOG) in the UK, the American College of
    Chest Physicians, and the British Society for Haematology. Because of the lack of
    RCTs, these guidelines are based mainly on expert opinion rather than high quality
    evidence.

 Conclusions:
  o Concerning implications for practice, the information currently available is
        insufficient to make any recommendations for practice.
    o Implications for research: there is a clear need for rigorously large scale RCTs
        with sample sizes sufficiently large to assess the effects of methods of
        thromboprophylaxis on rare outcomes such as thromboembolic events. No
        trials have yet assessed non-pharmacological methods of thromboprophylaxis
        during pregnancy and the postnatal period.




Dr. Khalid A. Yarouf (intern).                                                  Page 8 of 9
Ob Gyne Rotation: Internship.                       4MedStudents.com 11/5/2003
Morning Presentation: Maternal Mortality.




References

1. Maternal Mortality – United States, 1982-1996, JAMA, 1998 – Vol 280, No.
   12.
2. De Swiet M. Pulmonary embolism and hypertension remain the leading
   cause of maternal mortality in the United Kingdom, Am J Obstet Gynecol
   2000; 182: 760-6.
3. Nagaya K et al, Causes of Maternal Mortality in Japan, JAMA 2000; 283:
   2661-2667.
4. Gates S, Brocklehurst P, Davis LJ, Prophylaxis for venous thromboembolic
   disease in pregnancy and the early postnatal period, Cochrane Pregnancy
   and Childbirth Group, last updated 14-February-2002.
5. Cooper GM, Lewis G, Neilson J. Editorial I: Confidential enquires into
   maternal deaths 1997-1999, British Journal of Anaesthesia, 2002.
6. Hacker NF, Moore JG. Essentials of Obstetrics and Gynecology, 3rd ed,
   W.B. Saunders Company, p. 23-4, 1998.
7. Sharma S. Pulmonary Embolism, www.emedicine.com




Dr. Khalid A. Yarouf (intern).                                      Page 9 of 9

				
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