An audit of maternal deaths from a referral university teaching hospital in Nigeria: the emergence of HIV/AIDS as a leading cause

AIMS AND OBJECTIVES

To analyse the characteristics and causes of maternal death in a referral tertiary health facility in Southern Nigeria.

MATERIALS AND METHODS

This is a facility- based review of 184 maternal deaths that occurred from January 2005 to June 2009. Primary causes of death and factors that contributed to maternal death including delay in accessing health care were identified.

RESULTS

During the study period, the Maternal Mortality Ratio (MMR) was 2230/100,000 live births. There was a progressive reduction in the annual MMR from 2901/100,000 live birth in 2005 to 1459/100,000 live birth in 2009. More than four fifth (84.9%) of the maternal deaths occurred among women of low socio-economic class (IV and V). The leading causes of direct maternal deaths (64.1%) were Puerperal sepsis (17.8%), Pre-eclampsia/Eclampsia (15.8%) and complications of unsafe abortion (11.4%). HIV/AIDS was the third commonest overall cause of maternal death (15.2%). Half of the women experienced Type 1 delay (50%), Type 2 and 3 delay occurred in 7.6% and 18.5% of maternal deaths respectively. About two thirds of the women (58.2%) experienced more than one form of delay.

CONCLUSION

Although direct obstetric deaths remain the leading cause of maternal mortality, HIV/AIDS is becoming an important primary cause of maternal mortality in our environment. Organization of health service delivery with an effective referral system and the provision of optimal care for HIV infected women are recommended.

The efficacy of intramuscular loading dose of MgSO4 in severe pre-eclampsia/ eclampsia at a tertiary referral centre in Northwest Nigeria

AIMS AND OBJECTIVES

The efficacy of 10g intramuscular loading dose of magnesium sulphate in women with severe preeclampsia/eclampsia was assessed at a tertiary health centre for potential use at primary health level.

SUBJECTS AND METHODS

Intramuscular 10g loading dose and 14g loading dose of Pritchard were compared in women with severe preeclampsia/eclampsia. Primary outcome measures were the occurrence of fits in women with severe preeclampsia, further fits in those with eclampsia and maternal death. Other outcome measures were mode of delivery and severe birth asphyxia at 5 minutes of life.

RESULTS

One hundred and three women were enrolled; 54 and 49 women had 10g and 14g loading dose respectively. No significant convulsions (p= 0.1424) occurred in women with severe preeclampsia who had 10g intramuscular loading dose and repeat convulsion was averted in 93% of women with eclampsia. 10g loading dose did not increase the likelihood of caesarean section in women with preeclampsia (p=0.2832) or eclampsia (p=0.9112). The mean Apgar score at 5 minutes of life of neonates whose mothers had 10g and 14g loading dose for preeclampsia was 8 and 8.46 respectively, and 8.9 and 8.8 respectively for eclampsia. There was no statistically significant difference in maternal death between the two groups for severe preeclampsia (p= 0.2020) and eclampsia (p=0.3496).

CONCLUSION

This study suggests a potential use of intramuscular 10 gram loading dose of MgSO4 at the primary health care level in Nigeria.

[Preeclampsia - a life-time risk for the mother]

Preeclampsia is a pregnancy-induced disease associated with considerable maternal and fetal morbidity and mortality. While delivery usually results in a complete healing there is growing evidence that preeclampsia is a significant risk factor for cardiovascular and metabolic diseases in later life of these mothers. Especially early-onset, severity and number of deliveries with preeclampsia are relevant risk-factors. Preeclampsia itself could play a causative role or may just be a transient early symptom. An increasing understanding of these correlations is of major importance concerning health prevention and early detection of diseases in these young women.

Management of early onset severe preeclampsia in a tertiary hospital in India: does expectant management alter perinatal outcome?

OBJECTIVE

The aims of the study were to find out the maternal and perinatal outcome of early onset severe preeclampsia (PE) in a tertiary care center in a developing country like India and to determine whether expectant management in such a setup improves the perinatal outcome.

MATERIALS AND METHODS

It was a retrospective study. All women with early PE were admitted stabilized and evaluated. Expectant management was given whenever there was no indication for eminent delivery. The perinatal outcome of the expectant group was compared with that of the aggressive group, and appropriate statistical analysis was carried out.

RESULTS

A total of 106 women were admitted with severe PE, 61 were treated aggressively, and 45 were stable enough to receive expectant management. The total days gained on expectant management was 7 days. Perinatal mortality was 31.13%. Perinatal outcome of the expectant and aggressive management groups did not differ (P = 0.141); there was no increase in maternal complications on expectant management. There were 2 cases of maternal mortality in the aggressively managed group.

CONCLUSION

Perinatal mortality in severe PE is high. There was no increase in maternal morbidity on expectant management; however, there was no difference in perinatal mortality on expectant management.

China's process and challenges in achieving the United Nations Millennium

OBJECTIVE

China was categorized as one of the 68 "countdown" countries to achieve the United Nations Millennium Development Goals (MDG) 5. This paper aimed to analyze the situation of maternal survival, and coverage of proven cost effective interventions in China, where specific attention was paid to disparities.

METHODS

National maternal and child mortality surveillance data were used to estimate maternal mortality ratio (MMR). Coverage for proven interventions was analyzed based on National Health Services Survey, where experts' consultations were made for complementation.

RESULTS

There had been a significant reduction of MMR in China, however great disparities existed, with rural II to IV areas experiencing 2 to 5 times higher maternal mortality risks than urban areas and accounting for over 70% maternal mortality burdens. Postpartum hemorrhage, pregnancy associated hypertension, embolism and sepsis were the leading causes, and over 75% of the maternal mortality was caused by preventable or curable causes. Maternal health services utilization decreased in accordance with region's development level. Socioeconomic factors like financial difficulties were the main obstacles hindering access of care. Even those who made deliveries in hospitals faced different probabilities in receiving qualified care according to their socioeconomic standings.

CONCLUSION

China is on track to achieve MDG 5, however great disparities exist. It is necessary to specifically target rural types II to IV areas. Major causes of maternal mortality which can be prevented or averted through the provision of essential obstetrical care. Yet as compared with maternity health needs, insufficient coverage of maternal and child health (MCH) care services and poor service quality are the leading predisposing factors contributing to maternal mortality in China.

Prediction of adverse maternal outcomes in pre-eclampsia: development and validation of the fullPIERS model

BACKGROUND

Pre-eclampsia is a leading cause of maternal deaths. These deaths mainly result from eclampsia, uncontrolled hypertension, or systemic inflammation. We developed and validated the fullPIERS model with the aim of identifying the risk of fatal or life-threatening complications in women with pre-eclampsia within 48 h of hospital admission for the disorder.

METHODS

We developed and internally validated the fullPIERS model in a prospective, multicentre study in women who were admitted to tertiary obstetric centres with pre-eclampsia or who developed pre-eclampsia after admission. The outcome of interest was maternal mortality or other serious complications of pre-eclampsia. Routinely reported and informative variables were included in a stepwise backward elimination regression model to predict the adverse maternal outcome. We assessed performance using the area under the curve (AUC) of the receiver operating characteristic (ROC). Standard bootstrapping techniques were used to assess potential overfitting.

FINDINGS

261 of 2023 women with pre-eclampsia had adverse outcomes at any time after hospital admission (106 [5%] within 48 h of admission). Predictors of adverse maternal outcome included gestational age, chest pain or dyspnoea, oxygen saturation, platelet count, and creatinine and aspartate transaminase concentrations. The fullPIERS model predicted adverse maternal outcomes within 48 h of study eligibility (AUC ROC 0·88, 95% CI 0·84-0·92). There was no significant overfitting. fullPIERS performed well (AUC ROC >0·7) up to 7 days after eligibility.

INTERPRETATION

The fullPIERS model identifies women at increased risk of adverse outcomes up to 7 days before complications arise and can thereby modify direct patient care (eg, timing of delivery, place of care), improve the design of clinical trials, and inform biomedical investigations related to pre-eclampsia.

FUNDING

Canadian Institutes of Health Research; UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction; Preeclampsia Foundation; International Federation of Obstetricians and Gynecologists; Michael Smith Foundation for Health Research; and Child and Family Research Institute.

Preeclampsia mortality in Texas: a capture-recapture analysis

OBJECTIVE

Public health professionals and clinicians rely on hospital discharge data to explore the epidemiology of preeclampsia. Our objective was to compare the concordance in preeclampsia inpatient mortality between hospital inpatient discharge data and death certificate data in Texas during a 2-year period using the capture-recapture technique.

METHODS

The statewide Texas hospital inpatient discharge dataset and a statewide death certificate dataset were searched for fatal episodes of preeclampsia or eclampsia. Women who were Texas residents and expired in a hospital in 2006 or 2007 were identified using ICD-9-CM and ICD-10 codes. Using the capture-recapture sampling technique, we estimated the number of inpatient preeclamptic deaths that were missed by both databases, the death certificate database and the hospital inpatient database.

RESULTS

The hospital inpatient dataset captured 17 fatal episodes of preeclampsia while the inpatient death certificate database captured 9. Six patients were found in both datasets. Application of the capture-recapture method revealed that the total number of statewide inpatient preeclamptic deaths was 26 during this period.

CONCLUSIONS

This pilot study found that 2 prominent sources of statewide health data underestimated the frequency of inpatient deaths in Texas due to preeclampsia.

[Extreme maternal morbidity in the Hospital General Dr. Aurelio Valdivieso, Oaxaca Health Services]

BACKGROUND

Obstetric Morbidity Extreme (OME) is a promising addition to the investigation of maternal deaths and is used for the evaluation and improvement of maternal health services is defined as a severe obstetric complication that threatens the life of the pregnant woman and requires urgent medical intervention to prevent death of the mother.

OBJECTIVE

To identify association between diseases and obstetric morbidity Extreme.

MATERIAL AND METHOD

Transversal review analytical records. We searched for codes related to conditions that could cause extreme obstetric morbidity and the indirect causes that might cause it.

RESULTS

The prevalence of OME 21 per 1000 newborns, diseases with greater association were eclampsia, liver failure and preeclampsia yielded the highest OR and statistical significance, the association of OME derived from surgery despite having a high prevalence in the analysis showed no association, in the same way if other variables showed association but had no significance and confidence intervals are below the unit that is the case of renal failure, metabolic failure and blood transfusion.

CONCLUSIONS

The OME is caused by group entities specific disease (FLASOG) in most cases such as preeclampsia, eclampsia and obstetric hemorrhage.

[Effects of gestational age on perinatal outcomes in patients complicated with early onset severe preeclampsia]

OBJECTIVE

To analysis the relationship between gestational age and perinatal outcomes in patients complicated with early onset severe preeclampsia.

METHODS

Retrospective study was conducted on clinical documents of 221 patients with early onset severe preeclampsia (< 34 weeks) who delivered after 28 gestational weeks in Peking University First Hospital from July 1999 to June 2009. Patients were divided into three groups based on gestational weeks at delivery: group I (n = 81) delivered at 28 - 31 weeks(+6), group II (n = 78) at 32 - 33 weeks(+6) and group III (n = 62) after 34 weeks. The clinical characteristics and perinatal outcomes were compared among those three groups.

RESULTS

(1) Outcome of neonates: Among 221 neonates, 13 neonates lost follow-up, including 9 in group I, 3 in group II, 1 in group III. The incidence of neonatal respiratory distress syndrome (RDS) of 26% (19/72) in group I were significantly higher than 7% (5/75) in group II and 10% (6/61) in group III (P < 0.05). The neonatal mortality rate of (43%, 31/72) in group I were significantly higher than 3% (2/61) in group III and 28% (21/75) in group II (P < 0.05). The incidence of maternal complications showed no statistical difference among three groups. (2) Neonatal death analysis: all neonatal death were due to parents' give up, including 26% (8/31) in group I, 67% (14/21) in group II and 1/2 in group III, which reached statistical difference (P < 0.05).

CONCLUSIONS

The incidence of neonatal RDS in mother with early onset severe preeclampsia was decreased if delivered after 32 weeks, and the perinatal mortality was remarkably decreased if delivered after 34 weeks. Therefore, the perinatal survival rate in women with early onset severe preeclampsia can be improved by minimizing the impact of social factors.

Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems

BACKGROUND

Pre-eclampsia and eclampsia are common causes of serious morbidity and death. Calcium supplementation may reduce the risk of pre-eclampsia through a number of mechanisms, and may help to prevent preterm birth.

OBJECTIVES

To assess the effects of calcium supplementation during pregnancy on hypertensive disorders of pregnancy and related maternal and child outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2010) and contacted study authors.

SELECTION CRITERIA

Randomised trials comparing at least 1 g daily of calcium during pregnancy with placebo.

DATA COLLECTION AND ANALYSIS

We assessed eligibility and trial quality, extracted and double-entered data.

MAIN RESULTS

We included 13 studies of good quality (involving 15,730 women). The average risk of high blood pressure was reduced with calcium supplementation rather than placebo (12 trials, 15,470 women: risk ratio (RR) 0.65, 95% confidence interval (CI) 0.53 to 0.81). There was also a reduction in the average risk of pre-eclampsia associated with calcium supplementation (13 trials, 15,730 women: RR 0.45, 95% CI 0.31 to 0.65). The effect was greatest for high-risk women (five trials, 587 women: RR 0.22, 95% CI 0.12 to 0.42), and those with low baseline calcium intake (eight trials, 10,678 women: RR 0.36, 95% CI 0.20 to 0.65).The average risk of preterm birth was reduced in the calcium group overall (11 trials, 15,275 women: RR 0.76, 95% CI 0.60 to 0.97) and amongst women at high risk of developing pre-eclampsia recruited to four small trials (568 women: RR 0.45, 95% CI 0.24 to 0.83).There was no overall effect on the risk of stillbirth or death before discharge from hospital (11 trials 15,665 babies; RR 0.90, 95% CI 0.74 to 1.09). The composite outcome maternal death or serious morbidity was reduced (four trials, 9732 women; RR 0.80, 95% CI 0.65 to 0.97). Most of the women in these trials were low risk and had a low calcium diet. Maternal deaths were reported in only one trial. One death occurred in the calcium group and six in the placebo group, a difference which was not statistically significant (RR 0.17, 95% CI 0.02 to 1.39).Blood pressure in childhood has been assessed in two studies, only one of which is currently included: childhood systolic blood pressure greater than 95th percentile was reduced (514 children: RR 0.59, 95% CI 0.39 to 0.91).

AUTHORS' CONCLUSIONS

Calcium supplementation appears to approximately halve the risk of pre-eclampsia, to reduce the risk of preterm birth and to reduce the rare occurrence of the composite outcome 'death or serious morbidity'. There were no other clear benefits, or harms.

Tobacco Use During Pregnancy and Preeclampsia Risk

Preeclampsia is a leading cause of maternal and infant mortality and morbidity worldwide. Both Swedish snuff and cigarette smoke include nicotine, but combustion products accompany only smoking. The aims of this study were to compare the effects of Swedish snuff and cigarette smoking on preeclampsia risk and to estimate whether changes in tobacco habits during pregnancy affect the risk of developing term preeclampsia. We used information from the Swedish Birth Register on all singleton births in Sweden during the years 1999–2006 (n=612 712). Compared with nontobacco users, women who used snuff in early pregnancy had an adjusted odds ratio (OR) for preeclampsia of 1.11 (95% CI: 0.97 to 1.28). The corresponding ORs for light and heavy smokers were 0.66 (95% CI: 0.61 to 0.71) and 0.51 (95% CI: 0.44 to 0.58), respectively, with ORs lower for term than preterm preeclampsia. Compared with nontobacco users, women who smoked in early pregnancy but had quit smoking before late pregnancy (weeks 30 to 32) had an adjusted OR for term preeclampsia of 0.94 (95% CI: 0.83 to 1.08). The corresponding OR for women who did not use tobacco in early pregnancy but had started to smoke before late pregnancy was 0.65 (95% CI: 0.50 to 0.85). We conclude that tobacco combustion products rather than nicotine are the probable protective ingredients against preeclampsia in cigarette smoke. Because change of smoking habits during pregnancy influence risk, we further conclude that it is the smoking habits in the middle or late rather than in the beginning of pregnancy that seem to affect the risk of preeclampsia.

[Recommendations for medical management of women with preeclampsia]

When analyzing various recommendations formulated by the colleges of specialty, as well as precedents, the following guidelines can be formulated with respect to communication as part to the management of PE. These guidelines affect the professionals & the pregnant women within a healthcare network. Recommendations destined to the former include: Recommendations destined to the latter include:

Pre-eclampsia: aspirin beneficial

Two meta-analyses suggest that low-dose aspirin taken daily during pregnancy reduces the incidence of pre-eclampsia in women at risk and reduces mortality among the infants born to mothers at high risk of pre-eclampsia.

Maternal Deaths Associated with Hypertensive Disorders of Pregnancy: a opulation‐Based Study

There were 507 deaths associated with hypertensive disorders of pregnancy (eclampsia, preeclampsia, and chronic hypertension) in South Africa over the triennium 1999-2001. Eclampsia was associated with 289 deaths, preeclampsia with 139, and the remaining 79 with chronic hypertension, hemolysis, elevated lever enzymes, and low platelet count (HELLP) syndrome, liver rupture and acute fatty liver. The major final cause of death was intracranial hemorrhage. Other causes included HELLP syndrome and liver rupture. Contributory causes include pulmonary edema, renal failure/impairment, and disseminated intravascular coagulation. Deaths from eclampsia occurred at all levels of health care, in particular, there was still a considerable number of deaths at level I hospitals. Most deaths from eclampsia occurred at low parity (parity 0 = 51%), while 13% of deaths in noneclamptics occurred in women of parity > or = 5. Similarly, most deaths from eclampsia occurred in women aged < or = 24 years, while most in the noneclamptic group were aged 25 years and greater. The most common avoidable factors were patent-oriented problems--women who either presented late for antenatal care or late to hospital when symptomatic. Administrative factors also played a major role, in that there was a delay in referral due to the unavailability of transport. The lack of protocols of management or failure to follow clinical protocols of care contributed towards avoidable medical factors. Most women presented as an emergency event and failure of resuscitation/achievement of hemodynamic stabilization constituted a significant avoidable factor. Clear protocols for management of hypertension in pregnancy at all levels of health care are required.

The Importance of Parity to Major Maternal Morbidity in the Eclamptic Mother with Hellp Syndrome

OBJECTIVE

To determine if the rate of major morbidity from severe preeclampsia with/without hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome differs by parity.

METHODS

Retrospective investigation of 970 gravidas with severe preeclampsia with and without HELLP syndrome analyzed according to parity.

RESULTS

Altogether 609 (63%) patients were nulliparous and 361 (37%) parous. Between groups there was no significant difference in the incidence of overall major morbidity (21% vs. 19%, p=0.467), or specific morbidities including hematologic/coagulopathic (13.6% vs. 11.9%, p=0.442), cardiopulmonary (8.9% vs. 7.2%, p=0.362), CNS/visual (1.8% vs. 2.8%, p=0.319), or hepatorenal (0.8% vs. 2.2%, p=0.068). Although eclampsia was significantly more common in nulliparous (10.2%) than in parous patients (5.5%, p=0.012), the later significantly more often demonstrated major maternal morbidity associated with eclampsia (50%) than did nulliparous patients (25%, p=0.043).

CONCLUSIONS

Unless parous patients with severe preeclampsia with or without HELLP syndrome develop eclampsia, their disease acuity does not differ significantly from their nulliparous counterparts.

Severe pre-eclampsia and eclampsia in Abha, the south west region of Saudi Arabia

A retrospective study was conducted over a 10-year period on 32,000 maternities at Abha General Hospital, Abha, Saudi Arabia, to estimate the contribution of eclampsia and severe pre-eclampsia to maternal mortality and morbidity and also fetal wastage. It included 18 cases of eclampsia and 297 cases of severe pre-eclampsia. Multiple regression analysis revealed that only the presence of prodromal symptoms significantly affected the occurrence of eclampsia, p < 0.05, while nulliparous patients were a high risk group for eclampsia. Maternal complications including eight cases of massive ascites occurred exclusively in severe pre-eclamptics. Although no maternal deaths were reported, the perinatal mortality rate was 16.6% and 14.1% among the eclamptics and severe pre-eclamptic patients, mainly from prematurity. Regarding the eclamptic patients, 17(94.4%) had the first fit before arrival at the hospital, 13(72.2%) before labour, while 3(16.6%) had fits before and during labour and 1(5.6%) had the fits after delivery. Suggestions are proffered to reducing maternal morbidity and perinatal mortality and morbidity.

Pregnancy-associated acute liver disease and acute viral hepatitis: differentiation, course and outcome

BACKGROUND/AIMS

Pregnant women with acute viral hepatitis (VH) and those with pregnancy associated acute liver disease (PAALD) including acute fatty liver disease of pregnancy, hemolysis elevated liver enzyme and low platelet syndrome present with similar clinical features and liver tests abnormalities. Accurate differentiation between the two groups is critical to expedite early delivery in the latter and prevent progressive liver damage. There is scant data in the literature to differentiate between PAALD and VH.

METHODS

We studied the clinical variables, hematological, biochemical and viral serological tests of 87 consecutive pregnant patients with jaundice from 2000 to 2003.

RESULTS

There were 46 and 41 patients in PAALD and VH group, respectively. Two-thirds in VH group were due to hepatitis E. Univariate analysis identified hypertension, encephalopathy, oliguria, ascites, serum creatinine, and low platelets as significantly more common in the PAALD group. Multivariate analysis and recursive partitioning identified hypertension and ascites as predictors of PAALD with excellent predictive ability and c value of 0.92. Mortality was 41% in PAALD and 7.5% in VH. Increased bilirubin and oliguria were predictors of mortality in PAALD.

CONCLUSIONS

Presence of ascites and hypertension differentiates PAALD from VH and should prompt early delivery. Mortality due to hepatitis E is low.

Maternal mortality due to arterial hypertension in São Paulo City (1995-1999)

AIM

To describe the case profile of maternal death resulting from hypertensive disorders in pregnancy and to propose measures for its reduction.

METHODS

The Committee on Maternal Mortality of São Paulo City has identified 609 cases of obstetric maternal death between 1995 and 1999 with an underreporting rate of 52.2% and a maternal mortality rate of 56.7/100,000 live births. Arterial hypertension was the main cause of maternal death, corresponding to 142 (23.3%) cases.

RESULTS

Ninety-five (66.9%) of the deaths occurred during the puerperal period and 34 (23.9%) occurred during pregnancy. The time of death was not reported in 13 (9.2%) cases. Seizures were observed in 41 cases and magnesium sulfate was used in four of them. The causes of death were ruled to be cerebrovascular accident (44.4%), acute pulmonary edema (24.6%), and coagulopathies (14.1%). Cesarean section was performed in 85 (59.9%) cases and vaginal delivery in 15 (16.0%).

CONCLUSION

Complications of arterial hypertension are responsible for the high rates of pregnancy-related maternal death in São Paulo City. Quality prenatal care and appropriate monitoring of the hypertensive pregnant patient during and after delivery are important measures for better control of this condition and are essential to reduce disorders in pregnancy.