Pregnancy-related Maternal Deaths Research Articles

Pregnancy-related maternal deaths due to cardiovascular diseases in Japan from 2010 to 2019: an analysis of maternal death exploratory committee data

Objective Cardiovascular disease (CVD) is the leading cause of maternal deaths in high-income countries. This study aimed to assess the characteristics of maternal deaths due to CVDs and the quality of care provided to patients, and to identify elements to improve maternal care in Japan. Methods This descriptive study used the maternal death registration data of the Maternal Deaths Exploratory Committee of Japan between 2010 and 2019. Results Of 445 eligible pregnancy-related maternal deaths, 44 (9.9%) were attributed to CVD. The most frequent cause was aortic dissection (18 patients, 40.9%), followed by peripartum cardiomyopathy (8 patients, 18.2%), and pulmonary hypertension (5 patients, 11.4%). In 31.8% of cases, cardiopulmonary arrest occurred within 30 min after initial symptoms. Frequent symptoms included pain (27.3%) and respiratory symptoms (27.3%), with 61.4% having initial symptoms during the prenatal period. 63.6% of the patients had known risk factors, with age ≥35 years (38.6％), hypertensive disorder (15.9%), and obesity (15.9%) being the most common. Quality of care was assessed as suboptimal in 16 (36.4%) patients. Cardiac risk assessment was insufficient in three patients with preexisting cardiac disease, while 13 patients had symptoms and risk factors warranting intensive monitoring and evaluation. Conclusion Aortic dissection was the leading cause of maternal death due to CVDs. Obstetrics care providers need to be familiar with cardiac risk factors and clinical warning signs that may lead to impending fatal cardiac events. Timely risk assessment, patient awareness, and a multidisciplinary team approach are key to improving maternal care in Japan.

Factors associated with knowledge of the postpartum intrauterine contraceptive device and attitude towards its use among women attending antenatal care at Debre Tabor town, Northwest Ethiopia, 2021: a cross-sectional study

BackgroundIntrauterine contraceptive device is a highly effective, long-acting, reversible family planning method that is safe to use by most postpartum women including those who are breastfeeding. Family planning methods used mainly, the postpartum intrauterine contraceptive device can tackle unintended pregnancy, short birth intervals, and pregnancy-related maternal death. Knowledge and attitude about the postpartum intrauterine contraceptive device were significant predictors of subsequent method use. However, the magnitude, Knowledge, and attitude toward intrauterine contraceptive device is still low in Ethiopia. Nevertheless, limited studies were done to assess Knowledge and attitude toward the postpartum intrauterine contraceptive device and their associated factors. Therefore, this study aimed to assess Knowledge, Attitudes, and associated factors toward postpartum intrauterine contraceptive devices.ObjectiveThis study aimed to assess Knowledge, Attitudes, and associated factors toward postpartum intrauterine contraceptive devices among pregnant women attending antenatal care at Debre tabor town public health institutions Northwest Ethiopia, 2021.Methodsan institutional-based cross-sectional study was conducted from March 1- April–30/2021. Four hundred twenty-three participants were recruited by using a systematic random sampling technique. The data were collected through face-to-face interviews using a pretested and structured questionnaire. Multivariable logistic regression analyses were computed to identify factors associated with the outcome variable. An adjusted odds ratio with a 95% confidence interval was computed to determine the level of significance.ResultsKnowledge and attitude towards postpartum intrauterine contraceptive devices were found to be 36 and 48.7% respectively. Government employee (AOR = 4.98,95%CI:2.79–8.91), student (AOR = 5.29,95%CI:1.29–21.80), urban residence (AOR = 1.9095%CI: 1.02–3.53) and ever discussed on a postpartum intrauterine contraceptive device with health care provider (AOR = 6.01,95%CI:3.70–.7.44) were associated with the knowledge about the postpartum intrauterine contraceptive device. Attained secondary education (AOR = 3.22, 95%CI: 1.41–7.31), attended college and above education (AOR = 3.62, 95%CI: 1.75–7.51), government-employee (AOR = 2.76, 95CI:1.11–6.81), student (AOR = 32.10, 95%CI: 3.22–44.79), good knowledge,(AOR = 13.72, 95%CI: 6.63–28.42), ever discussed on a postpartum intrauterine contraceptive device with health care provider (AOR = 2.24,95CI:1.18–4.24), were associated with attitude toward postpartum intrauterine contraceptive device.Conclusion and recommendationknowledge and positive attitude toward postpartum intrauterine contraceptive devices were low as compared with other studies. Mothers’ employment status, residence, and discussions about a postpartum intrauterine contraceptive device with healthcare providers improve women’s knowledge about the postpartum intrauterine contraceptive device. Maternal educational status, occupational status, ever discussed postpartum intrauterine contraceptive devices with a health care provider and several antenatal cares follow up were improves women’s attitude towards the postpartum intrauterine contraceptive device. The finding highlights the importance of discussing postpartum intrauterine contraceptive devices during pregnancy, which in turn enhances the knowledge and attitude, of mothers about postpartum intrauterine contraceptive devices.

Anticoagulant use to treat VTE (venous thromboembolism) in pregnancy: a review

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a medical condition that occurs when a blood clot forms in a deep vein that major cause of pregnancy-related maternal death. As pregnancy progresses, the risk of hypercoagulability increases, fibrinogen, factors VII, VIII, X and VWF (Von Willebrand Factor), plasminogen activator inhibitor-1, plasminogen activator inhibitor-2 are increases and 40-60% protein S decreases. Therefore, anticoagulant drugs are the mainstay of therapy for patients with VTE. The review aimed to select the best anticoagulant for pregnancy women with VTE. A scoping review was used. The type of articles reviewed were original articles obtained from four electronic journal databases published within 2012-2021. The main therapeutic agent recommended for use in the prevention and treatment of VTE in pregnancy is low molecular weight heparin (LMWH). LMWH has better bioavailability than other anticoagulants, has a lower risk of maternal bleeding, thromboembolic, thrombocytopenia and osteoporosis. The use of LMWH is actually better, more comfortable and safety for patients.

Effects of Piloting a Safety Bundle for Severe Maternal Hypertension

Cardiovascular and coronary conditions account for 14% of pregnancy-related maternal deaths in Ohio. Severe maternal morbidity (SMM) occurs almost 100 times more frequently than maternal deaths. From 2016 to 2019, the SMM rate for Ohio’s non-Hispanic Black pregnant women was more than twice that of White pregnant women. All women deserve evidence-based intervention for persistent severe-range blood pressure to avoid preventable SMM and mortality.

The opioid epidemic: how have buprenorphine waivered OB/GYNs impacted treatment availability in New York?

Opioid use disorder (OUD) is a known risk factor for pregnancy-related maternal deaths and greatly contributes to other obstetrical and neonatal complications. Physicians are urged to obtain a US Drug Enforcement Administration (DEA) waiver (x-waiver) to reduce use associated risks through prescribing buprenorphine. This study aims to observe the number and geographic distribution of x-waivered physicians in New York (NY), with a focus on OB/GYN providers.

Suicide, Overdose Are Significant Contributors to Pregnancy-Related Maternal Deaths

Suicide, Overdose Are Significant Contributors to Pregnancy-Related Maternal Deaths

Venous Thromboembolism in Pregnancy [39L

INTRODUCTION: Venous thromboembolism is one of the leading causes of pregnancy-related maternal death in developed countries. The incidence rate is much higher during the postpartum period with an overall incidence of 2.5 to 9.9 per 1000 METHODS: The data were obtained from the 1999-2015 Health Care Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS) and used to carry out a population-based cohort study. The purpose of our study is to trend the rate of VTE during pregnancy and postpartum period and the assessment of the risk factors using a large population-based administrative database from the United States. Logistic regression was used to calculate the odds ratio (OR) and corresponding 95% confidence intervals (CIs) of demographic and obstetrical determinants of VTEs. RESULTS: The overall incidence of VTE was in an upward trend until 2015 when it reached 20/10,000 pregnancies, with an average case fatality rate of 1.16%. VTE is associated with maternal age above 25, anemia, heart disease, hypertension, obesity, transfusion, C-section, postpartum hemorrhage and PET. Predictors of VTE fatalities included obesity, hypertension, PET, postpartum hemorrhage, PTB and DM. CONCLUSION: VTE is a condition with an increasing in incidence and is associated with a significant maternal morbidity and mortality. Multiple risk factors associated with VTE with obesity being the most significant in our study. Further research targeting risk factors and prevention in pregnancy is warranted.

Assessment of reasons of maternal deaths – An autopsy study

Background: The distinction between maternal death in pregnancy and pregnancy-related maternal death is not always easy. The present study was conducted to determine reasons of maternal deaths.Materials & Methods: The present study was conducted in the department of forensic Medicine. It included 34 pregnancy related deaths. Demographic profile and histopathological findings were recorded. Reasons of deaths were recorded. Results: Age group 16-20 years had 8 cases, 20-24 years had 10 cases, 24-28 years had 6 cases, 28-32 years had 4 cases and age >32 years had 6 cases. The difference was significant (P

Trauma in Pregnancy: An Underappreciated Cause of Maternal Death

(Am J Obstet Gynecol 2017;217:499–500) While the maternal mortality ratio (MMR) drastically decreased from 1917 to 1980, the MMR in the United States has been steadily on the rise since 1980. Increased obesity, high maternal age, higher cesarean section rate and other factors may contribute to this increase. Currently, deaths from trauma in pregnant women are not counted in the MMR or pregnancy-related maternal death statistics and therefore many deaths are not captured.

Analysis of preventability of hypertensive disorder in pregnancy-related maternal death using the nationwide registration system of maternal deaths in Japan

Objective: Hypertensive disorder of pregnancy (HDP) is a major cause of maternal death. The goal of this study was to investigate factors associated with maternal death due to HDP.Study design: HDP-related maternal deaths in Japan reported to the Committee of the Ministry of Health, Labor and Welfare from 2010 to 2015 were examined.Results: Out of 47 cases of HDP, 30 were identified as the major cause of maternal death. The median maternal age was 34 years (range 24–45) and the mortality in women aged ≥40 years was seven times higher that than in women aged <34 years. The etiologies were intracerebral hemorrhage (n = 22), subarachnoid hemorrhage (n = 3), subcapsular hematoma of the liver (n = 2), peripartum cardiomyopathy (n = 2), and eclampsia (n = 1), and 19 cases were deemed preventable. The most frequent antepartum problems were delays in hospitalization, maternal transfer, and termination of pregnancy. In four cases, diagnosis of HELLP syndrome was too late because laboratory data were not checked, despite the patient reporting epigastric pain or showing elevation of blood pressure (BP). Treatment for lowering of BP was improper in 2/3 intrapartum cases, even though BP was elevated during pregnancy (144 versus 188 mmHg, p < .001). There was inadequate lowering of BP and lack of use of magnesium sulfate in 7/11 postpartum cases (64%), despite aspartate aminotransferase (AST) (p < .005), alanine aminotransferase (ALT) (p < .01), lactate dehydrogenase (LDH) (p < .005), and platelet count (PLT) (p < .01) all significantly worsening after delivery. Conclusion: HDP accounts for 11% of maternal deaths in Japan. Mothers aged ≥40 years are most at risk for HDP-related maternal death. Major concerns for preventabilities were late hospitalization, maternal transportation, and termination of pregnancy for term or near-term HDP. Regular vital checks and prompt lowering of BP were lacked during labor in most cases. HELLP syndrome should be managed at a general hospital with sufficient medical resources.

Re-Evaluating the Possible Increased Risk of HIV Acquisition With Progestin-Only Injectables Versus Maternal Mortality and Life Expectancy in Africa: A Decision Analysis.

The association between increased risk of HIV acquisition and use of progestin-only injectables (POIs) is controversial. We sought to compare the competing risks of maternal mortality and HIV acquisition with use of POIs using updated data on this association and considering an expanded number of African countries. We designed a decision-analytic model to compare the benefits and risks of POIs on the competing risks of maternal mortality and HIV acquisition on life expectancy for women in 9 African countries. For the purposes of this analysis, we assumed that POIs were associated with an increased risk of HIV acquisition (hazards ratio of 1.4). Our primary outcome was life-years and the population was women of reproductive age (15-49 years) in these countries, who did not have HIV infection and were not currently planning a pregnancy. Probabilities for each variable included in the model, such as HIV incidence, access to antiretroviral therapy, and contraceptive prevalence, were obtained from the literature. Univariate and multivariate sensitivity analyses were performed to check model assumptions and explore how uncertainty in estimates would affect the model results. In all countries, discontinuation of POIs without replacement with an equally effective contraceptive method would result in decreased life expectancy due to a significant increase in maternal deaths. While the removal of POIs from the market would result in the prevention of some new cases of HIV, the life-years gained from this are mitigated due to the marked increase in neonatal HIV cases and maternal mortality with associated life-years lost. In all countries, except South Africa, typical-use contraceptive failure rates with POIs would need to exceed 39%, and more than half of women currently using POIs would have to switch to another effective method, for the removal of POIs to demonstrate an increase in total life-years. Women living in sub-Saharan Africa cope with both high rates of HIV infection and high rates of pregnancy-related maternal death relative to the rest of the world. Based on the most current estimates, our model suggests that removal of POI contraception from the market without effective and acceptable contraception replacement would have a net negative effect on maternal health, life expectancy, and mortality under a variety of scenarios.

Nicotinamide benefits both mothers and pups in two contrasting mouse models of preeclampsia

Preeclampsia (PE) complicates ∼5% of human pregnancies and is one of the leading causes of pregnancy-related maternal deaths. The only definitive treatment, induced delivery, invariably results in prematurity, and in severe early-onset cases may lead to fetal death. Many currently available antihypertensive drugs are teratogenic and therefore precluded from use. Nonteratogenic antihypertensives help control maternal blood pressure in PE, but results in preventing preterm delivery and correcting fetal growth restriction (FGR) that also occurs in PE have been disappointing. Here we show that dietary nicotinamide, a nonteratogenic amide of vitamin B3, improves the maternal condition, prolongs pregnancies, and prevents FGR in two contrasting mouse models of PE. The first is caused by endotheliosis due to excess levels in the mothers of a soluble form of the receptor for vascular endothelial growth factor (VEGF), which binds to and inactivates VEGF. The second is caused by genetic absence of Ankiryn-repeat-and-SOCS-box-containing-protein 4, a factor that contributes to the differentiation of trophoblast stem cells into the giant trophoblast cells necessary for embryo implantation in mice; its absence leads to impaired placental development. In both models, fetal production of ATP is impaired and FGR is observed. We show here that nicotinamide decreases blood pressure and endotheliosis in the mothers, probably by inhibiting ADP ribosyl cyclase (ADPRC), and prevents FGR, probably by normalizing fetal ATP synthesis via the nucleotide salvage pathway. Because nicotinamide benefits both dams and pups, it merits evaluation for preventing or treating PE in humans.

Maternal Mortality in the Main Referral Hospital in Angola, 2010-2014: Understanding the Context for Maternal Deaths Amidst Poor Documentation.

Increasing global health efforts have focused on preventing pregnancy-related maternal deaths, but the factors that contribute to maternal deaths in specific high-burden nations are poorly understood. The aim of this study was to identify factors that influence the occurrence of maternal deaths in a regional maternity hospital in Kuando Kubango province of Angola. The study was a retrospective cross-sectional analysis of case notes of all maternal deaths and deliveries that were recorded from 2010 to 2014. The information collected included data on pregnancy, labor and post-natal period retrieved from case notes and the delivery register. During the period under study, a total of 7,158 live births were conducted out of which 131 resulted in maternal death with an overall maternal mortality ratio of 1,830 per 100,000 live births. The causes of death and their importance was relatively similar over the period reviewed. The direct obstetric causes accounted for 51% of all deaths. The major causes were hemorrhage (15%), puerperal sepsis (13%), eclampsia (11%) and ruptured uterus (10%). In addition, indirect non-obstetric medical causes such as Malaria, Anemia, hepatitis, AIDs and cardiovascular diseases accounted for 49% of all maternal deaths. There is poor documentation of personal data and clinical case management of cases. The factors of mutual instability of statistical significance associated with maternal death are: place of domicile (P=0.0001) and distance to the hospital (P=0.0001). The study demonstrated that the MMR in maternity hospital is very high and is higher than the WHO 2014 estimates and the province is yet to achieve the desired MDG 5 target by the end of 2015. A reversal of the present state requires data driven planning in order to improve access and use of Maternal Health Services (MHS) and ultimately lower the number of pregnancy-related maternal deaths.

Shift in Macrophage Polarity and Preeclampsia

Preeclampsia is a serious pregnancy disorder with incidence rates ranging from 3-7% [1] that causes approximately 14% of all pregnancy-related maternal deaths and 15% of premature births worldwide [2]. This condition is characterized by maternal hypertension, glomerular endotheliosis, and proteinuria which usually occur in the last trimester of pregnancy. The complete pathogenesis of preeclampsia is still unclear [3].

False-negative urine human chorionic gonadotropin in molar pregnancy: " The high-dose hook effect" !

Failure to detect pregnancy in the emergency situations can have important consequences. These include missing of ectopic pregnancy (the leading cause of first-trimester pregnancy-related maternal death), administration of medications contraindicated in pregnancy, fetal radiation exposure, and medico legal problems. This in turn has led to the dictum to check for pregnancy in all women of child-bearing age group. Urine pregnancy (human chorionic gonadotropin [hCG]) test is the commonly used test to rule out pregnancy and has been reported by Griffey et al. in their study to achieve 100% sensitivity and 99.2% specificity in a clinical setting, resulting in a positive predictive value of 98.3% and a negative predictive value of nearly 100%. However, the sensitivity is influenced not only by the quantity of β hCG but on its variants that vary with different weeks of pregnancy. β hCG is present in several variant forms that change in their concentrations at different stages of pregnancy. In spite of its high sensitivity, in the presence of molar pregnancy that is associated with very high levels of β hCG it fails to detect the antigen (β hCG). This is explained by the phenomenon known as high-dose hook effect which further leads to delay in diagnosis and treatment. This can be overcome by dilution of the sample. In such cases, diagnosis will be made by serum β hCG and ultrasound (USG). Here, we present a case of gravida 2 para 1 living 1 with 2΍ months amenorrhea with bleeding p/v and pain abdomen of 20 days duration whose urine β hCG was repeatedly negative and diagnosis was made by serum β hCG and USG.

Pregnancy after liver transplantation

Women constitute >30% of patients undergoing liver transplantation (orthotopic liver transplantation, OLT) and about 8% are of reproductive age, and 5% are pediatric females who will mostly survive into adulthood and will consider pregnancy. Although pregnancy in OLT recipients is associated with an increased incidence of hypertension, preeclampsia, anemia, preterm deliveries, and cesarean section, acute rejection and liver allograft loss do not appear to be increased and pregnancy-related maternal death is uncommon. The incidence of structural malformations in the newborn of liver transplant recipients is reported to be 4.4%, which is similar to the rate of 3-5% in the US general population. Patients are advised to defer conception for at least 1-2 years after OLT, while maintaining effective contraception. Pregnancy after OLT usually results in a favorable maternal and neonatal outcome when there is coordinated pre- and perinatal care by a multidisciplinary team composed of obstetric-gynecologists, and a transplant team.

Drug treatment of hypertension in pregnancy.

Hypertensive disorders represent major causes of pregnancy-related maternal mortality worldwide. Similar to the non-pregnant population, hypertension is the most common medical disorder encountered during pregnancy and is estimated to occur in about 6-8% of pregnancies. A recent report highlighted hypertensive disorders as one of the major causes of pregnancy-related maternal deaths in the USA, accounting for 579 (12.3 %) of the 4,693 maternal deaths that occurred between 1998 and 2005. In low-income and middle-income countries, preeclampsia and its convulsive form, eclampsia, are associated with 10-15% of direct maternal deaths. The optimal timing and choice of therapy for hypertensive pregnancy disorders involves carefully weighing the risk-versus-benefit ratio for each individual patient, with an overall goal of improving maternal and fetal outcomes. In this review, we have compared and contrasted the recommendations from different treatment guidelines and outlined some newer perspectives on management. We aim to provide a clinically oriented guide to the drug treatment of hypertension in pregnancy.

Pregnancy and long-term cardiovascular outcomes in women with congenitally corrected transposition of the great arteries

ObjectiveTo define maternal/neonatal outcomes and long-term cardiovascular effects of pregnancy in women with congenitally corrected transposition of the great arteries (ccTGA). MethodsClinical records of all women with ccTGA who were followed at a tertiary care center in Poland between April 1991 and April 2012 were retrospectively reviewed. ResultsOf the 20 pregnancies among 13 women identified, 19 (95%) were successful. Of the 19 deliveries, 14 (74%) were vaginal and 5 (26%) were cesarean. Cardiovascular complications during pregnancy and childbirth occurred in 3 patients (16% of successful pregnancies). Two women developed supraventricular arrhythmias; they were observed and required no pharmacologic treatment. One patient required premature delivery for documented deterioration of right ventricular function. There were no pregnancy-related maternal deaths. In 1 case, congenital heart disease was diagnosed in the offspring. With regard to long-term follow-up, no differences were found in terms of heart failure admissions, pharmacologic treatment, deaths, or echocardiographic parameters compared with non-pregnant women with ccTGA. ConclusionSuccessful pregnancy can be achieved by most women with ccTGA. The most common cardiovascular complications are supraventricular arrhythmias but pregnancy does not seem to impair right ventricular function in the long term. Nevertheless, preconception counseling and tertiary care during pregnancy for women with ccTGA are recommended.

The Role of Novel Biomarker in Early Prediction of Preeclampsia in Pregnant Rats

Preeclampsia has been known to be implicated in almost 20% of pregnancy-related maternal deaths and is also known to be the leading cause of a mandated preterm delivery. Pre-eclampsia is a medical condition associated with significant amounts of protein in urine in pregnant ladies reported with hypertension. As this is not a normal situation, the need for development of relevant biomarkers, rapid improvement in current diagnosis and the advancements in treatment is greatly required. The Cellular microparticles are either shed or secreted from cell membranes as endocytic vesicles which are termed as exosomes. In our investigation, evidence of accumulating exosomes in preeclamptic rats that modulate the antigen presentation, and are also capable of suppressing the immune response by exposing NkG2D-ligands has been investigated. The probability of such research on these vesicles and their putative clinical relevance are quite exciting and promising for the future upcoming research. The faster the disease is detected and confirmed with the help of such vesicles, the better would the maternal and fetal prognosis be diagnosed.

A Comprehensive Review of Hypertension in Pregnancy

Hypertension is the most common medical disorder encountered during pregnancy. Hypertensive disorders are one of the major causes of pregnancy-related maternal deaths in the United States. We will present a comprehensive update of the literature pertinent to hypertension in pregnancy. The paper begins by defining and classifying hypertensive disorders in pregnancy. The normal vascular and renal physiological changes which occur during pregnancy are detailed. We will summarize the intriguing aspects of pathophysiology of preeclampsia, emphasizing on recent advances in this field. The existing diagnostic tools and the tests which have been proposed for screening preeclampsia are comprehensively described. We also highlight the short- and long-term implications of preeclampsia. Finally, we review the current management guidelines, goals of treatment and describe the potential risks and benefits associated with various antihypertensive drug classes. Preeclampsia still remains an enigma, and the present management focuses on monitoring and treatment of its manifestations. We are hopeful that this in depth critique will stimulate the blossoming research in the field and assist practitioners to identify women at risk and more effectively treat affected individuals.