Maternal Death In Women Research Articles

Preeclampsia and neonatal outcomes in pregnancies with maternal congenital heart disease: A nationwide cohort study from Norway.

The prevalence of congenital heart disease (CHD) among women of reproductive age is rising. We aimed to investigate the risk of preeclampsia and adverse neonatal outcomes in pregnancies of mothers with CHD compared to pregnancies of mothers without heart disease. In a nationwide cohort of pregnancies in Norway 1994-2014, we retrieved information on maternal heart disease, the course of pregnancy, and neonatal outcomes from national registries. Comparing pregnancies with maternal CHD to pregnancies without maternal heart disease, we used Cox regression to estimate the adjusted hazard ratio (aHR) for preeclampsia and log-binomial regression to estimate the adjusted risk ratio (aRR) for adverse neonatal outcomes. The estimates were adjusted for maternal age and year of childbirth and presented with 95% confidence intervals (CIs). Among 1 218 452 pregnancies, 2425 had mild maternal CHD, and 603 had moderate/severe CHD. Compared to pregnancies without maternal heart disease, the risk of preeclampsia was increased in pregnancies with mild and moderate/severe maternal CHD (aHR1.37, 95% CI 1.14-1.65 and aHR 1.62, 95% CI 1.13-2.32). The risk of preterm birth was increased in pregnancies with mild maternal CHD (aRR 1.33, 95% CI 1.15-1.54) and further increased with moderate/severe CHD (aRR 2.49, 95% CI 2.03-3.07). Maternal CHD was associated with elevated risks of both spontaneous and iatrogenic preterm birth. The risk of infants small-for-gestational-age was slightly increased with mild maternal CHD (aRR 1.12, 95% CI 1.00-1.26) and increased with moderate/severe CHD (aRR 1.63, 95% CI 1.36-1.95). The prevalence of stillbirth was 3.9 per 1000 pregnancies without maternal heart disease, 5.6 per 1000 with mild maternal CHD, and 6.8 per 1000 with moderate/severe maternal CHD. Still, there were too few cases to report a significant difference. There were no maternal deaths in women with CHD. Moderate/severe maternal CHD in pregnancy was associated with increased risks of preeclampsia, preterm birth, and infants small-for-gestational-age. Mild maternal CHD was associated with less increased risks. For women with moderate/severe CHD, their risk of preeclampsia and adverse neonatal outcomes should be evaluated together with their cardiac risk in pregnancy, and follow-up in pregnancy should be ascertained.

Outcomes and quality of care for women and their babies after caesarean section in Nigeria.

To describe the outcomes and quality of care for women and their babies after caesarean section (CS) in Nigerian referral-level hospitals. Secondary analysis of a nationwide cross-sectional study. Fifty-four referral-level hospitals. All women giving birth in the participating facilities between 1 September 2019 and 31 August 2020. Data for the women were extracted, including sociodemographic data, clinical information, mode of birth, and maternal and perinatal outcomes. A conceptual hierarchical framework was employed to explore the sociodemographic and clinical factors associated with maternal and perinatal death in women who had an emergency CS. Overall CS rate, outcomes for women who had CS, and factors associated with maternal and perinatal mortality. The overall CS rate was 33.3% (22 838/68 640). The majority of CS deliveries were emergency cases (62.8%) and 8.1% of CS deliveries had complications after delivery, which were more common after an emergency CS. There were 179 (0.8%) maternal deaths in women who had a CS and 29.6% resulted from complications of hypertensive disorders of pregnancy. The overall maternal mortality rate in women who delivered by CS was 778 per 100 000 live births, whereas the perinatal mortality at birth was 51 per 1000 live births. Factors associated with maternal mortality in women who had an emergency CS were being <20 or >35 years of age, having a lower level of education and being referred from another facility or informal setting. One-third of births were delivered via CS (mostly emergency), with almost one in ten women experiencing a complication after a CS. To improve outcomes, hospitals should invest in care and remove obstacles to accessible quality CS services.

Perinatal outcome of maternal deaths at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, January 2014 - June 2019.

Maternal death is a tragic event. Of maternal deaths worldwide, 99% occur in low- and middle-income countries. Perinatal outcome is related to maternal wellbeing. Maternal death has a negative impact on fetal and neonatal outcome in the short and long term. To determine the perinatal outcomes of pregnancies that ended in a maternal death at Chris Hani Baragwanath Academic Hospital (CHBAH), Johannesburg, South Africa, over a 5-year period, to describe the causes of maternal death, and to determine the stillbirth rate (SBR) and early neonatal death (ENND) rate in this population. This was a retrospective cross-sectional study of maternal deaths in women with a viable pregnancy from January 2014 to June 2019 at CHBAH. All maternal deaths with gestation >26 weeks or fetal weight >500 g were included in the study. Information on demographics, booking status, antenatal care, pregnancy outcome, and fetal and neonatal outcome was extracted from maternal and neonatal files. Of a total of 183 maternal deaths during the study period, 147 were included in the study. The institutional maternal mortality ratio was 135 deaths per 100 000 live births. Hypertension was the main direct cause of death (36.5%; n=27/74), followed by pregnancy related sepsis (27.4%; n=21/74) and obstetric haemorrhage (20.6%; n=15/74). Non-pregnancy-related infections, of which 91.4% were HIV and HIV-related complications, comprised 47.9% (n=35/73) of indirect causes of death, followed by medical and surgical disorders. Of a total of 151 babies, including two sets of twins and one set of triplets, 137 were delivered and 14 were undelivered at the time of maternal death. Ninety-one babies (61.9%) were born alive and 51 (34.6%) were stillbirths. Of the 91 liveborn infants, 6 (6.5%) had an ENND. Of the 51 stillbirths, 14 (27.5%) were undelivered and 11 (21.6%) were delivered by perimortem caesarean section. The SBR was 347 per 1 000 maternal deaths and the ENND rate 66 per 1 000 live births. The perinatal mortality rate (PMR) was 388 per 1 000 maternal deaths, which is 12 times higher than the PMR per 1 000 live births for the general population. Women who experience maternal death have babies with very poor perinatal outcomes, with a very high SBR, ENND rate and PMR. The health of the mother has a direct and significant effect on fetal and neonatal outcomes.

Acute pain episodes, acute chest syndrome, and pulmonary thromboembolism in pregnancy

Pregnancy in women with sickle cell disease (SCD) is a life-threatening condition. In both high- and low-income countries, there is an 11-fold increased risk of maternal death and a 4-fold increased risk of perinatal death. We highlight the epidemiology of SCD-specific and obstetric complications commonly seen during pregnancy in SCD and propose definitions for acute pain and acute chest syndrome (ACS) episodes during pregnancy. We conducted a systematic review of the recent obstetric and hematology literature using full research articles published within the last 5 years that reported outcomes in pregnant women with SCD. The prevalence of acute pain episodes during pregnancy ranged between 4% and 75%. The prevalence of ACS episodes during pregnancy ranged between 4% and 13%. The estimated prevalence of pulmonary thromboembolism in women with SCD during pregnancy is approximately 0.5 to 1%. ACS is the most common cause of death and is often preceded by acute pain episodes. The most crucial time to develop these complications in pregnancy is during the third trimester and postpartum period. In a pooled analysis from studies in low- and middle-income settings, maternal death in women with SCD is approximately 2393 and 4300 deaths per 100 000 live births with and without multidisciplinary care, respectively. In comparison, in the US and northern Europe, the general maternal mortality rate is approximately 23.8 and 8 deaths per 100 000 live births, respectively. A multidisciplinary SCD obstetrics care approach reduces maternal and perinatal morbidity and mortality in low- and middle-income countries.

Maternal mortality in women with pre-viable premature rupture of membranes: An analysis from the French confidential enquiry into maternal deaths.

Pre-viable premature rupture of membranes (pre-viable PROM) is a rare event occurring in less than 1% of pregnancies. Nevertheless, it can be responsible for severe maternal complications, the risk of which needs to be balanced with the possibility to prolong the pregnancy up to viable gestational age. Maternal sepsis was reported in 1%-5% of women who received conservative management and prophylactic antibiotics, but information on maternal mortality is lacking. Our objective was to identify maternal deaths in women who had pre-viable PROM, describe the characteristics of the women, explore preventability factors within the care they received, and estimate the lethality of pre-viable PROM. We identified all maternal deaths associated with pre-viable PROM from the 2001-2015 French National Confidential Enquiry into Maternal Deaths (NCMM). Data on women's characteristics and the care they received were extracted from the ENCMM database. The lethality was determined after estimating the total number of pregnant women with pre-viable PROM from the national hospital discharge database. Between 2001 and 2015, we identified seven maternal deaths associated with pre-viable PROM, representing 0.6% of all maternal deaths over this period (ie, maternal mortality ratio 0.06/100 000 live births). Six maternal deaths were attributed to sepsis after genital infection by Gram-negative bacilli and one to postpartum hemorrhage due to placenta accreta. Four of these seven cases were considered preventable. The main preventability factors were delayed diagnosis, delayed fetal extraction, and inappropriate antibiotic treatment. The estimated lethality was 4.5/10 000 women with pre-viable PROM. Maternal death associated with pre-viable PROM is rare but possible. Most of these deaths seem preventable, with areas for improvement related to earlier diagnosis and better treatment of uterine infections, which can evolve rapidly.

Risk factors for adverse outcomes in women with high-risk pregnancy and their neonates, Haiti.

ABSTRACTObjectives.To determine the prevalence of maternal death, stillbirth and low birthweight in women with (pre-)eclampsia and complicated pregnancies or deliveries in Centre de Références des Urgences Obstétricales, an obstetric emergency hospital in Port-au-Prince, Haiti, and to identify the main risk factors for these adverse pregnancy outcomes.Methods.We conducted a retrospective cohort study of pregnant women admitted to Centre de Référence des Urgences Obstétricales between 2013 and 2018 using hospital records. Risk factors investigated were age group, type of pregnancy (singleton, multiple), type of delivery and use of antenatal care services.Results.A total of 31 509 women and 24 983 deliveries were included in the analysis. Among these, 204 (0.6%) maternal deaths (648 per 100 000 women giving birth), 1962 (7.9%) stillbirths and 11 008 (44.1%) low birthweight neonates were identified. Of all admissions, 10 991 (34.9%) were women with (pre-)eclampsia. Caesarean section significantly increased the risk of maternal death in the women with a complicated pregnancy and women with (pre-)eclampsia, but reduced the risk of stillbirth in such women. Not attending antenatal care was associated with a significantly higher risk of stillbirth (odds ratio (OR) 4.82; 95% confidence interval (CI) 3.55–6.55) and low birthweight (OR 1.40; 95% CI 1.05–1.86) for women with complicated pregnancies.Conclusion.To prevent and treat pregnancy complications as early as possible, antenatal care attendance is crucial. Improving the quality of and access to antenatal care services and providing it free to all pregnant women in Haiti is recommended.

Clinical characteristics, outcomes, & mortality in pregnant women with COVID-19 in Maharashtra, India: Results from PregCovid registry.

Background & objectives:The PregCovid registry was established to document the clinical presentations, pregnancy outcomes and mortality of pregnant and post-partum women with COVID-19.Methods:The PregCovid registry prospectively collects information in near-real time on pregnant and post-partum women with a laboratory-confirmed diagnosis of SARS-CoV-2 from 19 medical colleges across the State of Maharashtra, India. Data of 4203 pregnant women collected during the first wave of the COVID-19 pandemic (March 2020-January 2021) was analyzed.Results:There were 3213 live births, 77 miscarriages and 834 undelivered pregnancies. The proportion of pregnancy/foetal loss including stillbirths was six per cent. Five hundred and thirty-four women (13%) were symptomatic, of which 382 (72%) had mild, 112 (21%) had moderate, and 40 (7.5%) had severe disease. The most common complication was preterm delivery (528, 16.3%) and hypertensive disorders in pregnancy (328, 10.1%). A total of 158 (3.8%) pregnant and post-partum women required intensive care, of which 152 (96%) were due to COVID-19 related complications. The overall case fatality rate (CFR) in pregnant and post-partum women with COVID-19 was 0.8 per cent (34/4203). Higher CFR was observed in Pune (9/853, 1.1%), Marathwada (4/351, 1.1%) regions as compared to Vidarbha (9/1155, 0.8%), Mumbai Metropolitan (11/1684, 0.7%), and Khandesh (1/160, 0.6%) regions. Comorbidities of anaemia, tuberculosis and diabetes mellitus were associated with maternal deaths.Interpretation & conclusions:The study demonstrates the adverse outcomes including severe COVID-19 disease, pregnancy loss and maternal death in women with COVID-19 in Maharashtra, India.

Empowering midwives to manage postpartum haemorrhage in rural areas of Islamic Republic of Iran: lessons learnt from cases of maternal death.

Postpartum haemorrhage is the main cause of maternal mortality in rural areas of low-income countries. This study investigated the causes of maternal death from postpartum haemorrhage in rural areas of Sistan and Baluchestan, Islamic Republic of Iran, and determined the effect of three interventions on midwives' management of haemorrhage. Maternal deaths in women with postpartum haemorrhage between 9 April 2012 and 9 April 2013 were reviewed to determine what contributed to the death. Following the review, prostaglandin was permitted for use in rural maternity units. A flowchart on managing haemorrhagic shock and a training workshop on management of postpartum haemorrhage were also developed for midwives working in rural areas. After the interventions, all cases of postpartum haemorrhage (n = 81) that occurred during 23 September 2014-23 February 2015 in rural maternity facilities were reviewed based on 19 indicators. A control group (n = 81) was selected from women with postpartum haemorrhage who had been admitted to the same maternity units before the interventions. After the training interventions, more midwives used more than one method to estimate blood loss and higher doses of oxytocin to control haemorrhage. They showed improvements in the use of intravenous fluid therapy, pulse and blood pressure checks, external uterine massage, and uterotonic drugs. Following training, more women were admitted to hospital in a stable condition and recovered and were discharged (P = 0.002), and fewer had surgical interventions (P = 0.007). Midwives' management of postpartum haemorrhage improved after the interventions. Training programmes should be based on study of the local situation to identify shortcomings. Regular monitoring of outcomes is needed to detect and resolve failures.

Predicting seizures in pregnant women with epilepsy: Development and external validation of a prognostic model.

BackgroundSeizures are the main cause of maternal death in women with epilepsy, but there are no tools for predicting seizures in pregnancy. We set out to develop and validate a prognostic model, using information collected during the antenatal booking visit, to predict seizure risk at any time in pregnancy and until 6 weeks postpartum in women with epilepsy on antiepileptic drugs.Methods and findingsWe used datasets of a prospective cohort study (EMPiRE) of 527 pregnant women with epilepsy on medication recruited from 50 hospitals in the UK (4 November 2011–17 August 2014). The model development cohort comprised 399 women whose antiepileptic drug doses were adjusted based on clinical features only; the validation cohort comprised 128 women whose drug dose adjustments were informed by serum drug levels. The outcome was epileptic (non-eclamptic) seizure captured using diary records. We fitted the model using LASSO (least absolute shrinkage and selection operator) regression, and reported the performance using C-statistic (scale 0–1, values > 0.5 show discrimination) and calibration slope (scale 0–1, values near 1 show accuracy) with 95% confidence intervals (CIs). We determined the net benefit (a weighted sum of true positive and false positive classifications) of using the model, with various probability thresholds, to aid clinicians in making individualised decisions regarding, for example, referral to tertiary care, frequency and intensity of monitoring, and changes in antiepileptic medication. Seizures occurred in 183 women (46%, 183/399) in the model development cohort and in 57 women (45%, 57/128) in the validation cohort. The model included age at first seizure, baseline seizure classification, history of mental health disorder or learning difficulty, occurrence of tonic-clonic and non-tonic-clonic seizures in the 3 months before pregnancy, previous admission to hospital for seizures during pregnancy, and baseline dose of lamotrigine and levetiracetam. The C-statistic was 0.79 (95% CI 0.75, 0.84). On external validation, the model showed good performance (C-statistic 0.76, 95% CI 0.66, 0.85; calibration slope 0.93, 95% CI 0.44, 1.41) but with imprecise estimates. The EMPiRE model showed the highest net proportional benefit for predicted probability thresholds between 12% and 99%. Limitations of this study include the varied gestational ages of women at recruitment, retrospective patient recall of seizure history, potential variations in seizure classification, the small number of events in the validation cohort, and the clinical utility restricted to decision-making thresholds above 12%. The model findings may not be generalisable to low- and middle-income countries, or when information on all predictors is not available.ConclusionsThe EMPiRE model showed good performance in predicting the risk of seizures in pregnant women with epilepsy who are prescribed antiepileptic drugs. Integration of the tool within the antenatal booking visit, deployed as a simple nomogram, can help to optimise care in women with epilepsy.

Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis

Universal and timely access to a caesarean section is a key requirement for safe childbirth. We identified the burden of maternal and perinatal mortality and morbidity, and the risk factors following caesarean sections in low-income and middle-income countries (LMICs). For this systematic review and meta-analysis, we searched electronic databases including MEDLINE and Embase (from Jan 1, 1990, to Nov 20, 2017), without language restrictions, for studies on maternal or perinatal outcomes following caesarean sections in LMICs. We excluded studies in high-income countries, those involving non-pregnant women, case reports, and studies published before 1990. Two reviewers undertook the study selection, quality assessment, and data extraction independently. The main outcome being assessed was prevalence of maternal mortality in women undergoing caesarean sections in LMICs. We used a random effects model to synthesise the rate data, and reported the association between risk factors and outcomes using odds ratios with 95% CIs. The study protocol has been registered with PROSPERO, number CRD42015029191. We included 196 studies from 67 LMICs. The risk of maternal death in women who had a caesarean section (116 studies, 2 933 457 caesarean sections) was 7·6 per 1000 procedures (95% CI 6·6-8·6, τ2=0·81); the highest burden was in sub-Saharan Africa (10·9 per 1000; 9·5-12·5, τ2=0·81). A quarter of all women who died in LMICs (72 studies, 27 651 deaths) had undergone a caesarean section (23·8%, 95% CI 21·0-26·7; τ2=0·62). Maternal deaths and perinatal deaths following caesarean sections are disproportionately high in LMICs. The timing and urgency of caesarean section pose major risks. Ammalife Charity and ELLY Appeal, Barts Charity, and the UK National Institute for Health Research.

Maternal death in women with epilepsy

ObjectiveTo determine the maternal mortality in women with epilepsy.MethodsThis was a matched case-control study of pregnant women in Denmark who were born in Denmark between January 1, 1962, and December 31, 1994, and who were alive on their 18th birthday. We defined maternal mortality as deaths in pregnancy and the first 42 days after termination of pregnancy. Cases were pregnancies in women with a diagnosis of epilepsy before the termination of pregnancy. Data were analyzed with a conditional logistic model. For comparison, we estimated the mortality in women of childbearing age (18–50 years) diagnosed with epilepsy regardless of pregnancy status using a Poisson model.ResultsWe identified 2,105,084 pregnancies, including 11,976 (0.57%) pregnancies in which the mother was diagnosed with epilepsy. Of the 176 maternal deaths in this cohort, 5 women had a diagnosis of epilepsy. The mortality associated with an epilepsy diagnosis was >5 times higher compared to the mortality in women without this diagnosis (odds ratio 5.57, 95% confidence interval 2.23–13.9, p < 0.001).Conclusions and RelevanceMaternal mortality in women with epilepsy in Denmark was lower than what has previously been reported from United States and the United Kingdom. However, the maternal mortality in women with epilepsy was considerably higher compared to women without epilepsy. Further studies should address whether improving epilepsy care in women with epilepsy could reduce the rate of maternal deaths.

Risk of maternal mortality in women with severe anaemia during pregnancy and post partum: a multilevel analysis

Anaemia affects as many as half of all pregnant women in low-income and middle-income countries, but the burden of disease and associated maternal mortality are not robustly quantified. We aimed to assess the association between severe anaemia and maternal death with data from the WHO Multicountry Survey on maternal and newborn health. We used multilevel and propensity score regression analyses to establish the relation between severe anaemia and maternal death in 359 health facilities in 29 countries across Latin America, Africa, the Western Pacific, eastern Mediterranean, and southeast Asia. Severe anaemia was defined as antenatal or postnatal haemoglobin concentrations of less than 70 g/L in a blood sample obtained before death. Maternal death was defined as death any time after admission until the seventh day post partum or discharge. In regression analyses, we adjusted for post-partum haemorrhage, general anaesthesia, admission to intensive care, sepsis, pre-eclampsia or eclampsia, thrombocytopenia, shock, massive transfusion, severe oliguria, failure to form clots, and severe acidosis as confounding variables. These variables were used to develop the propensity score. 312 281 women admitted in labour or with ectopic pregnancies were included in the adjusted multilevel logistic analysis, and 12 470 were included in the propensity score regression analysis. The adjusted odds ratio for maternal death in women with severe anaemia compared with those without severe anaemia was 2·36 (95% CI 1·60-3·48). In the propensity score analysis, severe anaemia was also associated with maternal death (adjusted odds ratio 1·86 [95% CI 1·39-2·49]). Prevention and treatment of anaemia during pregnancy and post partum should remain a global public health and research priority. Barts and the London Charity.

Association between Maternal Mortality and Cesarean Section: Turkey Experience.

BackgroundTo investigate the cesarean Section (C/S) rates and maternal mortality (MM) causes and its relation between 2002 and 2013.MethodsData were gathered from Turkish Ministry of Health and Istanbul Health Administration. The Annual Clinical Reports for 2002–2013 were reviewed and analyzed: C/Ss and maternal deaths in women who gave birth ≥20 weeks between January 1, 2002, and December 31, 2013, in any hospital in Turkey and Istanbul.ResultsThe major causes of MM were hemorrhage (20%), hypertensive disorders (18.2%), embolism (10.3%), cardiovascular conditions (9%), infection (8.5%), and other causes (10.4%). Overall, the average annual CS delivery rate was 46.4% in Istanbul and 36.6% in Turkey. There was a significant increase in the CS rates in Istanbul and Turkey from 2008 to 2013 relative to those from 2002 to 2007 (p = 0.004). There was a statistically significant and inverse relationship (97.2%) between the MMR and CS rate from 2002 to 2013 in Turkey (p = 0.001). However, no significant relationship was detected between the MMR and CS rate from 2002 to 2013 in Istanbul (p > 0.05). There was a significant inverse correlation (66.3%) between the CS rate and peripartumhemorrhage in Turkey (p = 0.019) and there was a significant inverse correlation (66.5%) between the CS rate and peripartumhemorrhage(p = 0.018) in Istanbul between 2007 to 2013. There were no significant differences in ante-intrapartum haemorrhage bleeding (p > 0.05) or postpartum hemorrhage (p > 0.05) from 2007 to 2013.ConclusionsThis study demonstrates that there was a inverse correlation between increased CS and maternal mortality rates during the previous decade in Turkey. Although cesarean rates increase excessively, it appears that improved health care facilities have a positive effect on MMRs in Turkey.

MORTALIDAD MATERNA EN EL HOSPITAL NACIONAL EDGARDO REBAGLIATI MARTINS, I.P.S.S. EXPERIENCIA DE 25 AÑOS

En los primeros 25 años de existencia de nuestro Hospital hubo 154 muertes maternas en mujeres con un promedio de 31 años. 3.4 embarazos, hospitalizadas por estar en trabajo de parto (26%), por enfermedad hipertensiva inducida por el embarazo (9%), aborto séptico (12%). Las causas Obstétricas directas representaron el 71.4% de las muertes (110 casos), principalmente debidas a infección (25.3%), enfermedad hipertensiva (21.4%) y hemorragia (16.8%). El aborto séptico y la endometritis puerperal aumentaron en los últimos 10 años de estudio. Las muertes obstétricas indirectas (14.9%, 23 casos) se debieron principalmente a embolia pulmonar, trastornos cardiovasculares y necrosis hepática. Y en las muertes no obstétricas (13.6%, 21 casos) destacaron los procesos pulmonares y la infección generalizada. Nuestra aceptable tasa de mortalidad materna (48 por 100.000 recién nacidos vivos) disminuyó de 78 en el primer quinquenio a 41 en los últimos cinco años y probablemente se debió a la mejor condición de la paciente, cuidado pre natal satisfactorio y recursos hospitalarios y médicos adecuados.

Temporal evolution and spatial distribution of maternal death

OBJECTIVE To analyze the temporal evolution of maternal mortality and its spatial distribution.METHODS Ecological study with a sample made up of 845 maternal deaths in women between 10 and 49 years, registered from 1999 to 2008 in the state of Rio Grande do Sul, Southern Brazil. Data were obtained from Information System on Mortality of Ministry of Health. The maternal mortality ratio and the specific maternal mortality ratio were calculated from records, and analyzed by the Poisson regression model. In the spatial distribution, three maps of the state were built with the rates in the geographical macro-regions, in 1999, 2003, and 2008.RESULTS There was an increase of 2.0% in the period of ten years (95%CI 1.00;1.04; p = 0.01), with no significant change in the magnitude of the maternal mortality ratio. The Serra macro-region presented the highest maternal mortality ratio (1.15, 95%CI 1.08;1.21; p < 0.001). Most deaths in Rio Grande do Sul were of white women over 40 years, with a lower level of education. The time of delivery/abortion and postpartum are times of increased maternal risk, with a greater negative impact of direct causes such as hypertension and bleeding.CONCLUSIONS The lack of improvement in maternal mortality ratio indicates that public policies had no impact on women’s reproductive and maternal health. It is needed to qualify the attention to women’s health, especially in the prenatal period, seeking to identify and prevent risk factors, as a strategy of reducing maternal death.

Organ dysfunction and organ failure as predictors of outcomes of severe maternal morbidity in an obstetric intensive care unit.

Most of the maternal deaths are preceded by severe maternal morbidity (SMM). Organ dysfunction and organ failure may occur as part of the pathophysiologic spectrum in SMM. To determine the predictive and discriminative abilities of the Sequential Organ Failure Assessment (SOFA) scores to determine outcomes in pregnant women with SMM, who were admitted to a maternal ICU. A retrospective study design was used to ascertain the diagnostic effectiveness of Sequential Organ Failure Assessment (SOFA) scores. Maximum individual SOFA scores and total maximum SOFA score were compared between women with and without SMM, and in women with SMM who survived or did not survive. Primary outcome measure of interest was maternal mortality. A majority (n=73, 85.88%) of the 85 women in the study had obstetrics related causes. The total maximum SOFA score was significantly higher in women with SMM as compared to that in women without SMM (p<0.001). The total maximum SOFA score showed ability to discriminate pregnant women with SMM who would not survive (AUROC 0.77, 95% CI: 0.46, 1.00). The positive likelihood ratios and accuracy for total SOFA scores of ≥10 and ≥12 were 19.20 and 38.40, and 94.20% and 95.65% respectively. The post-test probabilities for maternal deaths in women with SMM for SOFA scores ≥10 and ≥12 were 60.01% and 75.01% respectively. The total maximum SOFA score showed good predictive and discriminative abilities for maternal mortality in pregnant women with SMM, who were admitted to ICU.

Maternal deaths in women with lupus nephritis: a review of published evidence

Pregnancies in women with systemic lupus erythematosus (SLE) and lupus nephritis are considered high-risk due to high rates of maternal and fetal complications. However, there has not been a formal analysis addressing the issue of maternal deaths in these women. The aim of this study was to perform a literature review of the maternal deaths in women with SLE and lupus nephritis to: (1) identify the main causes of death and (2) discuss possible reasons for these causes, and strategies that may improve patient care and outcomes. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENT: We performed an extensive electronic literature search from 1962 to 2009 using online databases (PubMed, Embase, Lilacs, Cochrane Controlled Trials Register, Medline, and Science Citation Index). Studies were included if they reported pregnancies in patients with SLE and lupus nephritis with at least one reported maternal death. We identified 13 studies that reported a total of 17 deaths in the 6 week post-partum period that were attributable to SLE and lupus nephritis. In all cases, death occurred in the setting of active disease, and was attributed either to infection in 41.2% (n = 7), or disease activity in 29.4% (n = 5). The remaining deaths were due to pulmonary embolus in 11.8% (n = 2), pregnancy-associated cardiomyopathy in 5.9% (n = 1), adrenal failure due to abrupt steroid withdrawal in 5.9% (n = 1), and undefined in 5.9% (n = 1). All maternal deaths in patients with SLE and lupus nephritis occurred in those with active disease, with disease activity/complications and infections (mainly opportunistic) being the two major causes. The presented evidence further supports timing of pregnancy relative to SLE activity, and the judicious use of immunosuppressive agents in pregnant patients.

Anticoagulação durante gravidez de mulher portadora de cardiopatia

Diretrizes em muito contribuem para minimizar os potenciais riscos obstétricos e fetais e melhorar a assistência durante o ciclo gravídico-puerperal. Contudo, há controvérsias a respeito do manuseio da anticoagulação em mulheres portadoras de cardiopatias. A importância deste assunto assenta-se no fato de que o tromboembolismo é considerado uma das principais causas de morte materna em portadoras de cardiopatia, o que torna obrigatório o conhecimento sobre sua prevenção. A estratégia do tratamento antitrombótico é ponderada pelo risco de trombose imposto pela situação clínica materna e pelos efeitos adversos que os anticoagulantes podem causar ao concepto. Neste artigo, serão discutidas a estratificação do risco materno ao tromboembolismo, as propriedades dos anticoagulantes indicados para a sua prevenção e a estratégia terapêutica nos diversos momentos da gestação, parto e puerpério da mulher portadora de cardiopatia.

Factors associated with maternal death in women admitted to an intensive care unit with severe maternal morbidity

Factors associated with maternal death in women admitted to an intensive care unit with severe maternal morbidity

Factors associated with maternal death in women admitted to an intensive care unit with severe maternal morbidity

Objective To identify factors associated with maternal death among women with severe maternal morbidity. Methods A retrospective study of 673 women admitted to an obstetric intensive care unit was undertaken. The odds ratios (OR) and 95% confidence intervals (95% CI) were calculated for selected characteristics. The maternal mortality and severe maternal morbidity ratios were determined for groups of complications according to outcome (death or survival). Results The risk of maternal death was higher among adolescents (OR 3.3; 95% CI, 1–9.7) and patients referred from other hospitals (OR 9.8; 95% CI, 2.7–53.3). The severe maternal morbidity ratio was 46.6 per 1000 deliveries and the mortality:morbidity ratio 1:37.4. Obstetric complications led to 65.8% of admissions and 50% of maternal deaths. The number of interventions/procedures and total maximum sequential organ failure assessment score were higher in cases of death. Conclusion The strong association between interhospital transfer and maternal death suggests delays in diagnosis, management, and referral. Adopting organ dysfunction-based criteria may contribute toward identifying the most severe cases.