Structure Of Maternal Mortality Research Articles

УСПЕШНОЕ ПРИМЕНЕНИЕ МЕТОДА ПОЛИМИКСИНОВОЙ СОРБЦИИ ЭНДОТОКСИНА В КОМПЛЕКСНОЙ ТЕРАПИИ ПАЦИЕНТКИ С ГРАМОТРИЦАТЕЛЬНЫМ СЕПСИСОМ ПРИ ПОЗДНЕМ ИНФИЦИРОВАННОМ ВЫКИДЫШЕ

Abstract. Introduction. Sepsis is one of the most serious problems of modern obstetrics, accounting for 11% of the overall structure of maternal mortality. One of the main initial causes of sepsis is endotoxin having diverse biological effects. Moreover, during sepsis development, endotoxin directly or indirectly leads to irreversible and often life-incompatible damage to organs. Columns for direct hemoperfusion with polymyxin B are used for extracorporeal endotoxin removal. Aim: Reviewing the literature on using columns with polymyxin B in sepsis treatment and describing our own clinical observation of maternal sepsis. Materials and Methods. Review of publications in electronic resources, such as PubMed, eLibrary, EMBASE, and Google Scholar. This article presents a clinical case of successful sepsis treatment during late infected miscarriage in a young patient. Results and Discussion. Currently published systematic reviews and meta- analyses prove the reduction of mortality in patients with sepsis/septic shock. A 39-year-old patient was admitted with signs of chorioamnionitis and incipient miscarriage at 20-21 weeks of pregnancy. After the delivery of a dead fetus, the picture of sepsis and septic shock developed. Removal of the uterus as the primary source of infection did not improve the woman’s condition. Positive changes were only observed after having applied the polymyxin sorption of endotoxin. This new advanced technology in medicine, thanks to the timely use, correct dose, and duration of hemoperfusion with polymyxin B, made it possible to remove bacterial endotoxins safely and effectively from the blood, which led to the successful sepsis therapy. Conclusions. Thanks to the coordinated actions of a multidisciplinary team of highly qualified specialists and the timely administration of adequate therapy, it was possible to save the patient’s life, thus preventing her from maternal mortality.

CIRCULATION IN THE BLOOD COMPOSITION OF PREECLAMPSIA PROGNOSTIC BIOMARKERS

The article, based on an analysis of modern literature, discusses the etiology and pathogenesis of the most dangerous complication of pregnancy - preeclampsia and the possibilities of predicting this pathology. The relevance of the problem associated with preeclampsia is due to its leading third position in the structure of maternal mortality, as well as serious long-term cardiometabolic disorders in women who have suffered this complication, which significantly reduce their quality of life. Based on the results of studying the pathogenesis of preeclampsia, new biomarkers (substances used as indicators of a biological state) were identified; this concept is used to characterize markers suitable for predicting a biological condition, such as preeclampsia, for early detection and prevention of this pathology.

The role of the development of thrombocytopathies in pregnant women with pre-eclampsia and the principles of their correction

One of the first places is occupied by obstetric bleeding, the second is preeclampsia, and the third is extragenital diseases in the structure of maternal mortality in the Republic of Uzbekistan. At the same time, it should be taken into account that in almost 80% of cases, bleeding is a consequence of preeclampsia (PE), and from a scientific point of view, it can be reasonably argued that I and II places should rightfully be for PE, therefore, this pathology is an urgent problem both scientifically and practical obstetrics.

Редкие клинические случаи эктопической беременности, прервавшейся во втором триместре гестации

In Russia in 2017, according to the Rosstat data, ectopic pregnancy in the structure of maternal mortality was 8.10%, and in 2018 it decreased by 2 times, amounting to 4.18%. The frequency of rare forms of ectopic pregnancy reaches 5-8.3%, and the course is characterised by massive bleeding, often with a fatal outcome. The article describes rare cases of ectopic pregnancy that have occurred in our clinical practice and were interrupted at the terms of 13 and 15-16 weeks with a favourable outcome, which will be interesting not only for practicing obstetricians and gynaecologists, but also doctors of other specialties. The difficulties in the diagnosis, as well as the tactics of management and surgical treatment of these patients are described.

Modern approaches to organ-conserving surgical hemostasis in obstetric bleeding

BACKGROUND: Obstetric hemorrhage is an urgent problem of global health care, since it occupies a leading position in the structure of maternal mortality. AIM: The aim of this study was to analyze data on hemostasis in obstetric bleeding. MATERIALS AND METHODS: The article presents a review of the world literature on modern approaches to hemostasis, which take into account new data on the anatomical structure of the female reproductive system. RESULTS AND CONCLUSIONS: Based on the foreign and domestic literature data, a strict step-by-step implementation of all prescribed measures along with a differentiated approach to treatment that takes into account anatomical features is the key to success in the fight against obstetric bleeding as the main cause of maternal mortality in the world.

Preeclampsia: Cardiotonic Steroids, Fibrosis, Fli1 and Hint to Carcinogenesis.

Despite prophylaxis and attempts to select a therapy, the frequency of preeclampsia does not decrease and it still takes the leading position in the structure of maternal mortality and morbidity worldwide. In this review, we present a new theory of the etiology and pathogenesis of preeclampsia that is based on the interaction of Na/K-ATPase and its endogenous ligands including marinobufagenin. The signaling pathway of marinobufagenin involves an inhibition of transcriptional factor Fli1, a negative regulator of collagen synthesis, followed by the deposition of collagen in the vascular tissues and altered vascular functions. Moreover, in vitro and in vivo neutralization of marinobufagenin is associated with the restoration of Fli1. The inverse relationship between marinobufagenin and Fli1 opens new possibilities in the treatment of cancer; as Fli1 is a proto-oncogene, a hypothesis on the suppression of Fli1 by cardiotonic steroids as a potential anti-tumor therapeutic strategy is discussed as well. We propose a novel therapy of preeclampsia that is based on immunoneutralization of the marinobufagenin by monoclonal antibodies, which is capable of impairing marinobufagenin-Na/K-ATPase interactions.

Clinical features and etiology of postpartum endometritis in women with a high risk of purulent-septic complications

Hypothesis/Aims of study. Postpartum purulent-septic complications continue to rank third in the structure of maternal mortality. In the etiology of postpartum endometritis, the key role is played by opportunistic microflora, including associations of microorganisms, as well as a history of chronic urogenital infection, bacterial vaginosis, and sexually transmitted infections. Despite numerous studies, the question of which microorganisms colonizing the birth canal are potentially dangerous in relation to the development of infectious and inflammatory pathology of the postpartum period is still a subject of discussion. The aim of this research was to study the etiology and identify the clinical features of postpartum endometritis in puerperas with risk factors for the development of purulent-septic complications.
 Study design, materials and methods. This retrospective comparative study included 199 puerperas, who were divided into two groups: the main group consisted of women who developed postpartum endometritis (n = 72), and the comparison group comprised women with the physiological course of the postpartum period (n = 127). Bacteriological examination of lochia was performed on the third day of the postpartum period, as well as with the development of postpartum endometritis before empirical antibiotic therapy was started.
 Results. During the bacteriological study of lochia in the main group of patients, potentially pathogenic microorganisms were observed in 68 % of puerperas, with the pathogen of endometritis not detected with repeated crops of lochia in 32 % of postpartum women. In the comparison group, this proportion was only 15 % (p 0.005). During pregnancy, the release of microorganisms from the cervical canal was observed in 26.4 % of cases in the main group and in 7 % of cases in the comparison group of puerperas (p 0.005). Despite the absence of clinical symptoms, all patients received systemic antibacterial therapy. Subsequently, 90 % of maternity patients in the main group revealed the ineffectiveness of empirical therapy due to antibiotic resistance of the identified microflora. When analyzing the species composition of microorganisms, intestinal microflora in monoculture was more often isolated in the patients of the main group: Escherichia coli (40 % vs. 2.4 % in the comparison group) and Enterococcus faecalis (25 % vs. 4.7 % in the comparison group). In 10 % of postpartum women with severe purulent-septic complications (sepsis, parametritis, pelvioperitonitis), the composition of the released microflora in lochiae did not differ from that of maternity women with endometritis without severe purulent-septic complications, and microbial associations were only detected in two cases.
 Conclusion. The etiological cause of postpartum endometritis in puerperas with risk factors for the development of purulent-septic complications is intestinal bacteria (Escherichia coli, Enterococcus faecalis) more often detected as a monoculture. The species composition of microorganisms that cause severe forms of postpartum purulent-septic complications does not differ in principle from the pathogens of uncomplicated forms of postpartum infection. Unreasonable antibacterial therapy during pregnancy is associated with antibiotic resistance of microorganisms that cause postpartum endometritis, which poses significant difficulties in the selection of antibacterial drugs for its treatment.

Анализ структуры материнской смертности

Анализ структуры материнской смертности

Преэклампсия, фиброз и маринобуфагенин

Preeclampsia is a life-threatening syndrome developing in pregnancy, the main features of which are hypertension and proteinuria. Frequency of preeclampsia has no tendency to decrease (3-7%), and it still takes the leading position in the structure of maternal mortality and morbidity worldwide. In this review, we present the “fibrotic concept” of the etiology and pathogenesis of preeclampsia, which involves system consisting of Na/K-ATPase and its endogenous ligands including marinobufagenin induced Fli1 inhibition. New therapy of preeclampsia includes modulation of the Na/K-ATPase system by immunoneutralization of marinobufagenin.

Акушерские причины материнской смертности. Результаты патологоанатомических исследований

Objective. To study the main causes of maternal mortality and to determine the role of obstetrical pathologies based on the findings of pathoanatomical autopsies. Materials and methods. The study included 42 autopsy findings, we studied medical documentation, autopsy records of deceased pregnant and parturient women. The most common causes of mortality (n = 29), according to the latest revision of ICD-10, were analyzed in detail. The general clinical and morphological examination was performed. Results. In Moscow, more than half of cases in the structure of maternal mortality refer to obstetrical pathologies. The most significant role belongs to preeclampsia and eclampsia (28.6%), they are in most cases characterised by an atypical clinical course and a specific pathomorphological picture. The second place is taken by massive pulmonary embolism (9.5%), the third place belongs to maternal shock during labour (7%) and the fourth place is shared by intrapartum infection (obstetrical sepsis), complications associated with obstetrical operative intervention and procedures, postpartum cerebral venous thrombosis, amniotic fluid embolism, postpartum cardiomyopathy (4.8%). Conclusion. The leading position in the structure of maternal mortality due to obstetrical causes belongs to preeclampsia and eclampsia. This pathology requires a complex approach to diagnosis and treatment, and postmortem verification of diagnosis should be confirmed by morphological examination with the use of immunohistochemical reactions. Key words: maternal mortality, obstetric pathology, preeclampsia and eclampsia, pulmonary embolism, maternal shock, obstetrical sepsis

Сравнительный анализ материнской смертности в Дальневосточном и Сибирском федеральном округах

Objective. To perform comparative analysis of parameters and structure of maternal mortality (MM) in the Far Eastern Federal District (FEFD) and Siberian Federal District (SFD) in 2014–2019. Materials and methods. The database for analysis was generated using map-based emergency notifications of maternal deaths (69 in FEFD and 180 in SFD). We used methods of descriptive statistics, Pearson's χ2-test, and calculated odds ratios (ORs) with 95% confidence intervals (95% CIs). Results. Between 2014 and 2018, the dynamics of MM in the FEFD and SFD had a one-way trend: it decreased in 2014–2017, but dramatically increased in 2018 primarily due to social factors. In 2019, we observed a significant growth of MM in the FEFD, while the SFD demonstrated a reduction of MM. The most common cause of maternal death in both districts was extragenital diseases. However, there were some differences in the structure of obstetric causes: in FEFD, preeclampsia and obstetric hemorrhage were the most frequent obstetric causes of death, while in SFD, women primarily developed embolism and placental abruption. Conclusion. The dynamics and structure of MM in the FEFD and SFD require management decisions aimed at improving medical care with the consideration of clinical guidelines, organization of continuous audit, systematic development of practical teamwork skills both in simulation training centers and healthcare institutions. Key words: Far Eastern Federal District, maternal mortality, Siberian Federal District

Endogenous Bufadienolides, Fibrosis and Preeclampsia.

Frequency of preeclampsia has no tendency to decrease, and it still takes the leading position in the structure of maternal mortality and morbidity worldwide. In this review, we present the “fibrotic concept” of the etiology and pathogenesis of preeclampsia which involves system consisting of Na/K-ATPase and its endogenous ligands including marinobufagenin. New therapy of preeclampsia includes modulation of the Na/K-ATPase system by immunoneutralization of the marinobufagenin and use of mineralocorticoid antagonists which are capable to impair marinobufagenin-Na/K-ATPase interactions.

Extragenital diseases, comorbidities, and polymorbidity in maternal death

To study the structure and significance of comorbidities and polymorbidity in maternal death. Sixty-five autopsy protocols of maternal deaths in the Novosibirsk Region in the period of 1994 to 2018 were analyzed. Extragenital diseases are the leading diseases in the nosological structure in maternal mortality. Preeclampsia/exlampsia and obstetric hemorrhages lost their leading positions. The increasing role of extragenital pathology in the structure of maternal mortality is due to many factors, such as a larger number of comorbidities and polymorbidity, in pregnant women. Infectious diseases, benign and malignant tumors, and diseases of the heart and blood vessels are the main diseases in the structure of extragenital diseases.

The increasing importance of extragenital pathology in the structure of maternal mortality in Russia

to determine the proportion of direct obstetric and indirect extragenital causes of maternal deaths in Russia in recent years. Official statistical data on maternal mortality in Russia were analyzed according to the criteria of the 10th revision of the International Classification of Diseases and compared with those in European countries and the USA. In the past 10 years, Russia has registered a gradual decline in the single maternal mortality rate: 27.7 in 2005, 18.6 in 2010, 12.9 in 2013, 11.9 in 2014, 10.7 in 2015, and 8.3 in 2016 per 100,000 live births. This was mainly due to a substantial decrease in obstetric losses and to the expansion of a network of well-equipped perinatal centers. Stabilization of the proportion of extragenital causes was simultaneously found. Among them in 2014, cardiovascular diseases were a dominant cause of death (51.7%), followed by respiratory diseases (29.8%) and digestive diseases and other conditions (18.2%). The demographic, socioeconomic, and medical conditions for extragenital causes were analyzed and compared with those in European countries and the USA. Recommendations were given to improve the postmortem analysis of maternal deaths in Russia. It is necessary to improve the postmortem diagnosis of the direct and indirect causes of maternal deaths and to ensure the quality and completeness of autopsies in deceased women.

The content of matrix metalloproteinase-12 in pregnancy complicated by preeclampsia

Relevance. Pre-eclampsia is the most difficult and important problem in obstetrics, it ranks third in the structure of maternal mortality. Until now, there is no single idea of the mechanisms of development of this pathological process. The study of the concentration of MMP-12 in pregnancy will determine its possible role in the development of pre-eclampsia.
 Aim. Сompare the dynamics of the concentration of matrix metalloproteinase-12 (MMP-12) in pregnancy complicated and not complicated by preeclampsia.
 Materials and methods. A prospective study of two groups of women: the main group is pregnant (n = 17) with preeclampsia (moderate (n = 11) and severe (n = 6)), the comparison group is women whose pregnancy was not complicated by preeclampsia (n = 83). The concentration of matrix metalloproteinase-12 was determined by the method of enzyme immunoassay in serum at 11-13, 22-24, 32-34 weeks of gestation.
 Results. In the group of pregnant women without preeclampsia, there was a sharp decrease in the concentration of MMP-12 from the I trimester to II (p = 0.0001), followed by a slight increase to the III trimester. In the group of pregnant women with preeclampsia, an increase in the concentration from the I trimester to II (p = 0.0001) was established. A significant difference in the concentration of MMP-12 between groups in the first trimester of pregnancy was shown (p = 0.0001).
 Conclusion. Thus, the results of the study indicate the role of MMP-12 in the initial stages of placentation.

Новий погляд на проблему діагностики післяпологових гнійно-запальних захворювань

Postpartum infectious diseases are ranked second (WHO, 2016) in the structure of maternal mortality and complicate postpartum period. Most of the existing methods allow to diagnose diseases in the presence of an already deployed clinical picture. The objective: of the work is to improve the diagnosis and prediction of pospartum endometritis by applying the method of fluorescence spectroscopy. Materials and methods. The main group is -120 women in the postpartum period with postpartum endometritis, the control group is 38 women with uncomplicated postpartum period. A study of their blood serum was carried out using the method of fluorescence spectroscopy. Results. Within the framework of the study, independent prognostic factors of the emergence of postpartum endometritis are inflammatory diseases of the lower department of the genital tract (p=0.01), abnormalities of labor (p=0.006) and TORCH infections (p=0.001). True markers for diagnosis of postpartum endometritis are the reduction in blood serum fluorescence intensity (IF) (p<0.0001) and the shift in magnitude lmax to the long-wave region (p=0.007). Conclusion. The use of spectrum-fluorescent blood serum markers in the comprehensive diagnosis of postpartum endometritis allows to diagnose reliably thе onset and to predict the course of the disease, including the treatment process. Key words: endometritis, postpartum purulent inflammatory diseases, method of fluorescence spectroscopy.

The diagnostics of sepsis in pregnant women and during postpartum period: the controversial questions of surviving sepsis campaign (International Guidelines for Management of Sepsis and Septic Shock), updated in 2016

Sepsis and septical shock clinical criteria were agreed in Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2016. Despite the imperfections of SIRS criteria (low specificity), their sensitivity reaches 100%. According to modern ideas, sepsis is a systemic inflammatory response to infection (Systemic Inflammatory Response Syndrome – SIRS) always associated with the presence of infectious agent in the body. Clinical and metabolical manifestations of sepsis are similar to symptoms and criteria of system inflammatory response syndrome. Physiological features of pregnant women are making adjustments to the classical picture of diagnosis and treatment. In the first trimester of pregnancy 15% of women are suffering from dyspnea. Increased heart rate is normal manifestation of the third mechanism of regulation of cardiac output (volume of circulating blood – first, the contractile ability of the myocardium – second). Increase in the number of leukocytes in peripheral blood of pregnant/postpartum women is a physiological process and creates difficulties in diagnostic process. The aim of study was to determine peculiarities of sepsis and septical shock in pregnant and postpartum women according to instructions of Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. The problem of sepsis is currently very severe in obstetrics. In now days, infections occupy third place in the structure of maternal mortality and make up about 15%. Systemic manifestations of sepsis/septical shock in pregnant/postpartum women (including the development of multiple organ dysfunction) can significantly outpace local changes of purulent source. If the primal source of infection is located in the uterus, the development of septical shock is not always accompanied by symptoms of “classical” metroendometritis, making it difficult to diagnose. It also detains radical sanation of the infectious source contributing to progression of multiple organ dysfunction. In 2001 E.P. Rivers et al. published an article in highly ranked journal N Eng J Med, which is cited by various authors until now. The whole algorithm of infusion and inotropic therapy was developed on its basis for patients with sepsis and septic shock. Despite this, in present time many authors doubt in expediency of achieving CVP 8-13 mmHg (J.H.Boyd et al 2011; M.Cessoni et al 2011; Marik P.E. et al 2008)., sodium ions accumulate in the extracellular space (interstitial and intravascular) in pregnant; as a result tissues become hydrophilic and tissue “phisiological edema” develops. Given the presence of capillary loss syndrome in pregnant/ postpartum women (preeclampsia / eclampsia) controversial is the question of the qualitative composition of the infusion therapy. There are no safe antibiotics for pregnant women according to Food and Drug Administration – FDA (USA). Therefore, the problem of antibiotic therapy in these patients also have its own features. Physiological features of pregnant woman are making adjustments to the classical picture of diagnosis and treatment of sepsis/septical shock in this group of patients. The aim of study was to determine peculiarities of sepsis and septical shock in pregnant and postpartum women according to instructions of Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. The problem of sepsis is currently very severe in obstetrics. In now days, infections occupy third place in the structure of maternal mortality and make up about 15%.In this article we have discussed the results of the diagnosis and treatment of 14 pregnant /postpar tum women with sepsis, who came to the clinic of anesthesiology and intensive care of the Lviv Regional Hospital from 2010 to 2016.Chorioamnionitis and endometritis were the main reasons of peritonitis and sepsis. Intensive therapy (volemic resuscitation, cardio-respiratory support, antibiotic therapy) and surgical intervention (eliminating the causes of peritonitis, sanitation and drainage of the abdominal cavity) were conducted to all the patients. The patient’s general condition was evaluated by APACHE II scale at 14,5 ± 1,5 points and multiple organ dysfunction was evaluated at 5,0 ± 1 points by SOFA scale.

Clinical and diagnostic criteria of cholestatic hepatosis severity in pregnancy

Discussed analyze the incidence and structure of maternal mortality from extra-genital diseases in Saint Petersburg the 1996-2014. Indicator of maternal mortality all the more depend from social factors and increase in the frequency of extra-genital diseases in reproduction ages woman.

La mortalidad materna : ¿Un problema de salud en vías de control?

El objetivo de este trabajo es estudiar el nivel, la tendencia, los cambios y la estructura de las causas específicas de la mortalidad materna en algunos países de Latinoamérica. Para ello se ha revisado información proveniente de los archivos de mortalidad de la Organización Panamericana de la Salud y alguna publicada por Naciones Unidas. El análisis muestra que el nivel de la mortalidad materna en los países de la región examinados es, en general, alto. Igualmente son preocupantes los pocos cambios que se observan en la tendencia de la razón de mortalidad materna entre 1988 y 1996 en la mayoría de estos países. El nivel de la mortalidad materna registrado representa una diferencia de entre 5 y 7 veces respecto a las tasas reportadas por Estados Unidos o Gran Bretaña. Adicionalmente, la heterogeneidad de los valores de la razón de mortalidad materna en la región refleja el esfuerzo desigual en la lucha contra este problema. La estructura de la mortalidad materna por causas específicas refleja las carencias en torno a la atención prenatal y del parto, particularmente respecto a la identificación temprana de patologías como la toxemia y de complicaciones en el puerperio. Asimismo indica que el aborto es un problema cuyo abordaje requiere la expansión de acciones en torno a la planificación familiar. Finalmente se hace una revisión de los diversos aspectos que deben considerarse al diseñar una respuesta integral al alto nivel que la mortalidad materna todavía tiene en la región.