Indirect Causes Of Maternal Death Research Articles

POSTPARTUM PITUITARY NECROSIS: A REPORT OF 2 AUTOPSY CASES

Major hormonal changes emerge during pregnancy. The pituitary gland is one of the most affected organs with altered anatomy and physiology. Sheehan’s syndrome also known as Simmonds’s syndrome or postpartum anterior pituitary necrosis is due to ischemicnecrosis secondary to blood loss and hypovolemic shock after child birth. We report two autopsy cases of postpartum anterior pituitary necrosis with their clinical correlation. Histopathological examination of pituitary in both the cases showed extensive areasof coagulative necrosis involving the anterior pituitary. Both the cases were associated with indirect causes of maternal deaths like infectious etiology.

Dealing with late maternal death due to cardiovascular disease

Globally, cardiac disease is emerging as an important indirect cause of maternal death. Cardiac conditions can be pre-existing, such as the case with rheumatic heart disease or congenital heart disease which can be unmasked by the increased haemodynamic load in pregnancy, or they can be caused by pregnancy, e.g. hypertensive disorders or peripartum cardiomyopathy (PPCM).

Assessment of Maternal Mortality and its Associated Causes at Shinyanga Regional Hospital in Tanzania

Background: Maternal mortality remains a public health concern in low income countries particularly in sub-Saharan Africa where majority (62%) of maternal deaths occurs. In Tanzania maternal mortality ratio is as high as 432 deaths per 100,000 live births. Objectives: This study aimed to describe pattern of maternal mortality ratio and its associated causes at Shinyanga regional referral hospital. We also assessed the availability of the comprehensive emergency obstetric care services in the study setting. Methods: This was retrospective cross-sectional study which was conducted from April to May 2015 at Shinyanga Regional Referral Hospital. Information on demographic data, obstetric factors associated with maternal death and their causes as well as their management were extracted from the patient’s record file between 2010 and 2014 by using data extraction sheet. Data analysis was performed using SPSS version 18.0 for Windows (SPSS Inc, Chicago, IL, USA). Descriptive statistical analysis were summarized. Results: Overall maternal mortality ratio declined from 635/100,000 live births in 2010 to 449/100,000 live births in 2014. The main causes of maternal death were postpartum haemorrhage (50%) and pre-eclampsia/eclampsia (20%). Majority (77%) of the delays were encountered at hospital and at home (56%). Numerous forms of management were provided to women who experienced maternal death including C-section (35.5%) for antepartum haemorrhage and hysterectomy (17%) for postpartum haemorrhage. For pre-eclampsia/eclampsia, only 12.5% had C-section. Of all of the maternal deaths, only 2.5% had assisted vaginal delivery and 14% had puerperal sepsis. Conclusions: The observed maternal mortality ratio in this population is higher compared to the national average. Postpartum haemorrhage and preeclampsia/eclampsia remains to be the main direct causes of maternal deaths. Delay in decision making in seeking fortreatment and provision of treatment contributed to high maternal mortality observed in this study. This requires more effort to address the direct and indirect causes of maternal death.

HIV self-care practices during pregnancy and maternal health outcomes among HIV-positive postnatal mothers aged 18–35 years at Mbuya Nehanda maternity hospital

ABSTRACTHIV-related conditions are one of the indirect causes of maternal deaths in Zimbabwe and the prevalence rate was estimated to be 13.63% in 2009. The study utilised a descriptive correlational design on 80 pregnant women who were HIV positive at Mbuya Nehanda maternity hospital in Harare, Zimbabwe. Participants comprised a random sample of 80 postnatal mothers. Permission to carry out the study was obtained from the respective review boards. Participants signed an informed consent. Data were collected using a structured questionnaire and record review from 1 to 20 March 2012. Interviews were done in a private room and code numbers were used to identify the participants. Completed questionnaires were kept in a lockable cupboard and the researcher had sole access to them. Data were analysed using the Statistical Package for Social Sciences (SPSS) version 12. Descriptive statistics were used to analyse data on demographics, maternal health outcomes and self-care practices. Inferential statistics (Pearson’s correlation and regression analysis) were used to analyse the relationship between self-care practices and maternal health outcomes. Self-care practices were good with a mean score of 8 out of 16. Majority (71.3%) fell within the good category. Maternal outcomes were poor with a mean score of 28 out of 62 and 67.5% falling in the poor category. Pearson’s correlation indicated a weak significant positive relationship (r = .317, p = <.01). Regression analysis (R2) was .10 implying that self-care practices explained 10% of the variance observed in maternal health outcomes. More research needs to be carried out to identify other variables affecting maternal outcomes in HIV-positive pregnant women.

A Study on Pattern of Heart Disease and Maternal and Fetal Outcome of Pregnancy in a Tertiary Level Hospital

Background: Cardiac disease is the most common cause of indirect maternal deaths and the most common cause of death overall. It complicates 1% of maternal death.Objective: Management of pregnancy in patients with valvular heart disease continues to pose a challenge to the clinician.the present study was therefore design to find the pattern of Heart Disease and to evaluate the maternal and fetal outcome of pregnancy. Method: This is a cross sectional study done during the period Jan to Dec, 2011in fetomaternal medicine wing of department of Obs &amp; Gynae, BSMMU. All the patients admitted with heart disease in pregnancy during this study period were included in this study. This study prospectively enrolled 54 pregnant women with heart disease.All cases were followed during pregnancy , labour, delivery and in early puerperium.Results: The mean (SD±) age of the patients was 26.08 ± 3.96 ranging from 20 to 35yrs, most ( 26% ) belonged to age group 26 - 30yrs and five (9.26% ) belonged to &gt;30years of age group. Most of the patients 21 (38.89%) were primigravid and 16(29.63%) patients were of second gravida. Out of 54 patients 41(75.93%) women received regular antenatal checkup.Thirty eight(70.37%) patients suffered from rheumatic heart disease. Twenty patients had single valvular involvement, either mitral, tricuspid or pulmonary valve with or without complication. Most of the patients had EF &gt;50% and two patients had EF &lt;49%. Two patients had mild mitral stenosis( &gt;1.5cm2), 5 patients had moderate mitral stenosis (1-1.5cm2) and 6 patients had severe mitral stenosis (&lt;1cm2).Conclusion: Patients with heart disease should be meticulously managed preconceptionally up to the postpartum period by maternal-fetal medicine specialists, obstetricians, cardiologists, and anesthesiologists using a multi-disciplinary approach to their cardiac conditions to have a better outcome of mother and baby.University Heart Journal Vol. 11, No. 1, January 2015; 36-41

Maternal mortality in Yazd Province, Iran.

IntroductionFive hundred thousand maternal deaths occur each year worldwide, many of which are in developing countries. The maternal mortality rate is a measure that demonstrates the degree of adequacy of prenatal care and of economic and social conditions. The aim of this study was to determine the frequency and causes of pregnancy-related mortality rates in Yazd Province.MethodsThis cross-sectional study examined the maternal deaths related to pregnancy that were recorded in Yazd Province, Iran, from 2002 to 2011. All maternal deaths that occurred during pregnancy, during delivery, and 42 days after birth were analyzed in this study. The data were collected through a questionnaire, and both direct and indirect causes of maternal deaths were determined.ResultsForty pregnancy-related deaths occurred in this period, and the maternal mortality rate was 20.8 deaths per 100,000 live births. The mean age of death in the mothers in this study was 29.17. Fifty-five percent of women of the women who died delivered their babies by cesarean section, and only 20% of them delivered their babies vaginally. Bleeding was the most common cause of maternal mortality (30%), and it was associated directly with maternal mortality. Furthermore 20% of the mothers died due to heart disease and cardiac complications, which were associated indirectly with maternal mortality.ConclusionCesarean section and its complications were the main cause of death in many cases. Thus, providing a strategic plan to reduce the use of this procedure, educate mothers, and ensure adequate access to pre-maternal care and to care during pregnancy are the most important measures that can be taken to decrease the maternal mortality rate.

Presentación del Simposio Acceso al Aborto Terapéutico en el Perú

A pesar de que el aborto terapéutico (AT) está aprobado por ley en el Perú desde el año 1924 (1), solo recientemente desde el Ministerio de Salud (junio 2014) ha sido aprobada la Guía Nacional para Interrupción Voluntaria del Embarazo por Razones Terapéuticas (2). Sin embargo, las mujeres peruanas aún no disponen de un adecuado acceso a los servicios en los hospitales públicos. Esta deficiencia es en gran medida responsable de que las causas indirectas de muerte materna se presenten cada vez con mayor frecuencia (3). Los profesionales de la salud de los establecimientos públicos que prestan servicios de salud sexual y reproductiva carecen de información suficiente y mantienen aún estigmas contra las mujeres que se interrumpen la gestación y contra los profesionales que las atienden, debido a que falta aún estandarizar la atención, para seguridad de las mujeres y de los profesionales.

Editorial

Editorial

Spectrum of pregnancy with heart diseases in Menoufia governorate

Objective: The aim of this study was to assess the spectrum of pregnancy with heart diseases in Menoufia governorate. Background: Heart diseases during pregnancy are the leading indirect cause of maternal death worldwide.Although the incidence of cardiac abnormalities during pregnancy has remained more or less unchanged, the relative contribution of the different causes of heart disease preceding or diagnosed during pregnancy varies with study population and study period. Patients and methods: This is a cross-sectional study of pregnant women with heart disease who underwent delivery between January 2012 and January 2013 at University Hospital and Shebin El Kom Teaching Hospital (Menoufia, Egypt). Maternal and fetal outcome and complications were evaluated for each patient. Results: The overall prevalence of pregnant women with heart disease was 9.3%. Hypertensive disorders during pregnancy were the most common cardiac disease diagnosed in our study (83%); native and prosthetic valvular heart diseases were present in 10 and 1.1%, respectively, whereas cardiomyopathy and congenital heart disease were present in 5.7 and 0.2%, respectively. The most prevalent maternal complication was bleeding (4.8%). Most women had spontaneous vaginal deliveries (57.4%), although 42.6% of women underwent cesarean sections. The most prevalent neonatal complications were premature birth (1.5%), babies requiring incubator support or on mechanical ventilation (7.8%), and fetal mortality (1.7%). Conclusion: Women of child-bearing age who are at risk for, or already have, cardiovascular disease should receive early counseling and treatment not only from their family physician but also from an interdisciplinary team comprising gynecologists, cardiologists, and, if necessary, cardiac surgeons.

Attitudes of midwives and maternal child health nurses towards suicide: A cross-sectional study.

Perinatal women are at risk of depression and/or suicidality. Suicide is the highest cause of indirect maternal deaths in the perinatal period. Midwives and maternal child health nurses (MCHN), as key clinicians, need to be able to detect these mental health issues. Little is known about these clinicians' attitudes to suicide. In this paper, we report on the results of a cross-sectional study of midwives' and MCHN attitudes to suicide. A convenience sample of midwives (n = 95) and MCHN (n = 86) from south-eastern Victoria, Australia, was recruited into the study. Participants completed the Attitudes to Suicide Prevention Scale. The results showed that MCHN have more positive attitudes towards suicide prevention than midwives, and younger participants have more positive attitudes to suicide prevention compared to older participants. Midwives and MCHN could benefit from continuing professional education to build their knowledge and skills in assessing suicide risk for childbearing women and their families, increasing positive attitudes, improving detection, and mental health referrals.

Grossesse chez les patientes ayant un antécédent de cardiopathie ischémique – Série de cas et revue de la littérature

Heart diseases complicate 1 to 3% of pregnancies and are the leading cause of indirect maternal deaths. Prior ischaemic heart event in pregnant patients is increasing. Most knowledge is based on few reports and there are no French nor international recommendations about the specific management of these patients. The specificity of the management of these patients during pregnancy, delivery and post-partum depends on the severity of the prior cardiac event and its consequences. This will be illustrated by the report of four recent cases managed in our hospital. First patient had myocardial infarction with normal left ventricular ejection fraction (LVEF). Second patient had a Tako-Tsubo syndrome with LVEF 45%. Third patient had ischemic cardiopathy with LVEF 30%. Fourth patient had myocardial infarction with LVEF 20%. A multidisciplinary follow-up should be required, especially in patients with severe ventricular dysfunction. The risk of fetal growth restriction appears to be increased, suggesting that closer ultrasound monitoring is necessary.

Maternal Mortality in Taiwan: A Nationwide Data Linkage Study.

BackgroundTo examine the changes in the maternal mortality ratio (MMR) and causes of maternal death in Taiwan based on nationwide linked data sets.MethodsWe linked four population-based data sets (birth registration, birth notification, National Health Insurance inpatient claims, and cause of death mortality data) to identify maternal deaths for 2004–2011. Subsequently, we calculated the MMR (deaths per 100,000 live births) and the proportion of direct and indirect causes of maternal death by maternal age and year.FindingsBased on the linked data sets, we identified 236 maternal death cases, of which only 102 were reported in officially published mortality data, with an underreporting rate of 57% [(236−102) × 100 / 236]. The age-adjusted MMR was 18.4 in 2004–2005 and decreased to 12.5 in 2008–2009; however, the MMR leveled off at 12.6 in 2010–2011. The MMR increased from 5.2 in 2008–2009 to 7.1 in 2010–2011 for patients aged 15–29 years. Women aged 15–29 years had relatively lower proportion in dying from direct causes (amniotic fluid embolism and obstetric hemorrhage) compared with their counterpart older women.ConclusionsApproximately two-thirds of maternal deaths were not reported in officially published mortality data. Routine surveillance of maternal mortality by using enhanced methods is necessary to monitor the health status of reproductive-age women. Furthermore, a comprehensive maternal death review is necessary to explore the preventability of these maternal deaths.

English

AIMS AND OBJECTIVES: Maternal death is a preventable tragedy. The aim of this study is to analyze the causes of maternal mortality in a tertiary centre. MATERIAL AND METHODS: The study was conducted by reviewing the records for maternal deaths over the period of one year 1-08- 2013 to 31-07-2014 in the Department of Obstetrics and Gynecology, Guntur Medical College, Guntur. Every maternal death was scrutinized for various aspects likely to be related to death such as age, locality of residence, antenatal care, admission death interval and the cause of death. RESULTS: The maternal mortality in the present study is 788/ 1 lakh live births. There were 62 maternal deaths in the study period. Most deaths occurred in the 20-25 age group. 51.6% of deaths occurred in the first seventy two hours after admission. Hypertensive disorders (25.80%) and hemorrhage (12.5%) are the two most common direct causes of maternal death. Post-operative and post abortal sepsis, amniotic fluid embolism, pulmonary embolism and peripartum cardiomyopathy are the other direct causes. Indirect causes of maternal deaths were seen in 34.9% of the cases. Hepatitis (9.64%), severe anemia is the two leading indirect causes of maternal deaths. CONCLUSION: Most of the maternal deaths can be prevented if the high risk antenatal women are identified earlier and referred to the

Respiratory diseases in pregnancy

Pulmonary diseases are one of the major indirect causes of maternal deaths. Pregnancy is a unique physiologi- cal state during which changes occur in all systems of the body to meet metabolic needs of both the mother and growing foetus. Enlarging uterus and increasing hormonal levels cause changes in volumes and mechanics of lungs. Understanding the basic physiology of the cardiovascular and respiratory changes during pregnancy along with the pathology of disease processes are vital in making therapeutic decisions. Pre-existing conditions like asthma, tuberculosis, and acute illnesses like pneumonia, acute respiratory distress syndrome (ARDS), pneumothorax can have calamitous effect on mother and child health. Continual foetal monitoring throughout pregnancy is very important in early recognition of foetal jeopardy.

Manejo anestésico para craneotomía en paciente gestante con rotura de malformación arteriovenosa cerebral: Reporte de caso

Intracranial haemorrhage (ICH) is the third leading non obstetric indirect cause of maternal death. We describe the anaesthetic management of a 32-year-old woman at 22weeks gestation with intracranial haemorrhage due to a ruptured arteriovenous malformation (AVM). Managing these patients requires a complex approach with a highly individualised plan involving neurosurgeons, neuroradiologists, anaesthetists, obstetricians and neonatologists to assess the risk and benefit of all the different therapeutic alternatives. Given the high risk of further bleeding during pregnancy and the location of the AVM, the best therapeutic option in this case was considered to be a craniotomy and complete removal of the lesion.

Anaesthetic management for craniotomy in a pregnant patient with rupture of a cerebral arterio-venous malformation: Case report

Intracranial haemorrhage (ICH) is the third leading non-obstetric indirect cause of maternal death. We describe the anaesthetic management of a 32-year-old woman at 22 weeks gestation with intracranial haemorrhage due to a ruptured arteriovenous malformation (AVM). Managing these patients requires a complex approach with a highly individualised plan involving neurosurgeons, neuroradiologists, anaesthetists, obstetricians and neonatologists to assess the risk and benefit of all the different therapeutic alternatives. Given the high risk of further bleeding during pregnancy and the location of the AVM, the best therapeutic option in this case was considered to be a craniotomy and complete removal of the lesion.

Missing mums-to-be &amp; smartphone technology: Addressing antenatal clinic DNAs with novel uses of a mobile application

Introduction: A student-led initiative has developed a free smartphone application to be piloted at the Women’s & Children’s Hospital (WCH) within the Hull and East Yorkshire NHS Trust to improve attendance at antenatal clinics following consultation with the patient population and local clinicians. The application interfaces directly with local public transport service resources to aid geographical access to antenatal clinic in addition to providing appointment reminders, a pregnancy tracker and basic healthcare information. Background & Context: Our review of antenatal clinic at the WCH identified an almost 6% Did Not Attend (DNA) rate costing the trust a direct cost of around £54,000/annum(1). This cost is in addition to the various negative health outcomes observed when women fail to attend regular antenatal clinics. The Saving Mother’s Lives report(2) showed that a third (32%) of the women who died in the period 2006-2008 failed to regularly attend antenatal appointments. The top three direct causes of maternal death in the UK are all associated with better health outcomes for the mother who regularly attends antenatal appointments(2). The same can also be said for the top three indirect causes of maternal death(2). Women who fail to attend any antenatal appointments have increased risk of low birth weight children, foetal death & neonatal death (5.46, 12.05 & 10.03, odds ratios compared to control, respectively)(2). Our team hypothesised that offering a free smartphone application with appointment reminders and public transport data could potentially improve attendance at clinics following extensive consultation with local clinicians and patients. We carried out a survey amongst women attending the antenatal service to assess interest and viability of the project. We determined there was an 89% smartphone adoption rate amongst this population (n= 91), with 84% identifying that use of a smartphone app would be useful. 9% of the population was identified as: having a smartphone, finding the concept useful & also having issues with attending antenatal appointments due to International Digital Health and Care Congress, The King’s Fund, London, September 10-12 2014. International Journal of Integrated Care – Volume 14, 01 November – URN:NBN:NL:UI:10-1-116517– http://www.ijic.org/ geographical access. All patients who indicated difficulties in attending clinic were within this category. Innovation: We developed a smartphone application that will directly interface with NHS systems to help the patient to keep track of their appointments for smartphones running Google Android or Apple’s iOS. We have integrated data from Travel South Yorkshire to offer public transport information based on GPS data obtained in real time from the smartphone. The mobile application also offers important health information to the woman regarding her pregnancy. This is all displayed in an intuitive format with a graphical representation of the woman’s journey through pregnancy. Impact: By addressing the needs of the patient sub-population identified through our questionnaire (i.e. geographical access issues) we hope to improve patient outcomes and decrease financial losses by improving attendance rates at antenatal clinic at the WCH. We hope to integrate this application into a suite of mobile applications currently being developed by the Hull & East Yorkshire NHS Trust and upon its deployment we aim to audit its effectiveness in a clinical setting.

PMM.06 Five-year experience of maternal cardiac disease in a district general hospital 2008–2012

CMACE 2008 has shown that the overall rate of mortality from cardiac disease has tripled over the last two decades being, the largest cause of indirect maternal death; mainly due...

PMM.78 Pregnancies in women with cardiac disease- experience of a tertiary centre following establishment of obstetrics-cardiology services

The incidence of cardiac disease in pregnancy is increasing and cardiac disease remains the leading cause of indirect maternal deaths. Management in pregnancy is highly specialised and requires early diagnosis,...

Attainment of the Fifth Millennium Development Goal: Utopia or Reality Based on Trends in Maternal Mortality in 12 Years in Two Regional Hospitals in Fako Division, Cameroon? A Retrospective Study

Introduction: According to WHO, globally an estimated 585,000 women die each year from complications of pregnancy and childbirth. One of the targets of Millennium Development Goal 5 (MDG 5) is to reduce maternal mortality by three quarters of the 1999 value by the year 2015. However, three years to 2015, very little is known on the trends in maternal mortality ratio, causes of maternal deaths and their associated factors in the Tiko Cottage Hospital (TCH) and Limbe Regional Hospital (LRH) in the South-West Region, Cameroon. Methods: This was a retrospective, analytical cross-sectional study that was carried out from 1st January 2000 to December 2012. After obtaining ethical clearance, the records of cases of maternal deaths and a reference group of women who survived after a pregnancy during the same period were carefully reviewed. The data were analyzed with SPSS 10 and EPI 3.5.1. Results: There were 14,480 live births and 132 maternal deaths during the study period, giving an adjusted Maternal Mortality Ratio (MMR) of 892/100,000 live births. Patients’ age ranged from 15 - 40 years (SD 2.3). We observed a downwards trend of Maternal Mortality Ratio (MMR). Seventy-eight percent of the maternal deaths were due to direct causes. The triad of hemorrhage (54.5%), abortions (17.4%), and eclampsia (10.6%) was the leading cause of death. HIV-related complications and hepatitis constituted the main indirect causes of maternal death. In 85.4% of cases, maternal deaths were avoidable. Lack of blood for transfusion and late referral of cases were the main avoidable factors. Patients less than 35 years (p = 0.01), no antenatal care (ANC) (p = 0.001), unemployment [OR = 1.52; 95% CI: (1.38 - 48.28); p = 0.02] were significantly associated with maternal deaths while grand multiparity [OR = 1.20; 95% CI (0.30 - 4.86); p = 0.79], marital status [OR = 1.20; 95% CI: (0.70 - 2.07); p = 0.51] and education level were not significantly associated with maternal deaths. Conclusion: The trend shows that there was no appreciable decline in maternal mortality, implying that attaining the objectives of MDG 5 is very unlikely. Therefore, to meet the MDG 5 target, we recommend that, there should be amelioration towards obstetric emergencies care and health education by health care providers.