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De Mucio B, F. CGS, S. NM. Morbilidad Materna Extremadamente Grave: un paso clave para reducir la muerte materna. REVISTA MÉDICA CLÍNICA LAS CONDES 2023. [DOI: 10.1016/j.rmclc.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
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Muacevic A, Adler JR. Intravenous Carbetocin Versus Rectal Misoprostol for the Active Management of the Third Stage of Labor: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cureus 2022; 14:e30229. [PMID: 36246091 PMCID: PMC9555680 DOI: 10.7759/cureus.30229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 11/07/2022] Open
Abstract
Globally, postpartum hemorrhage (PPH) is the top cause of maternal death. Multiple uterotonic medications are available to prevent PPH; however, it is still unclear whether one is the most effective. The current study compared the efficacy and safety of intravenous carbetocin with rectal misoprostol for the active management of the third stage of labor in order to prevent PPH. Eligible studies were found utilizing digital medical sources, including the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science (WOS), PubMed, Scopus, and Google Scholar, from inception until September 2022. Only randomized controlled trials (RCTs) that matched the inclusion requirements were chosen. We used the Cochrane Risk of Bias scale (version 2) to assess the quality of the included studies. The Review Manager (version 5.4 for Windows) was used to conduct the meta-analysis. The results were summarized as mean difference (MD) or risk ratio (RR) with a 95% confidence interval (CI) in fixed- or random-effects models according to the degree of between-study heterogeneity. Collectively, we screened 621 articles after omitting duplicates and eventually included three RCTs for analysis. Overall, 404 patients were included in these studies; 202 patients were allocated to the intravenous carbetocin group whereas 202 patients were allocated to the rectal misoprostol group. Two RCTs were judged as “low” risk of bias, whereas one RCT was judged as having “some concerns” regarding the quality assessment. Regarding efficacy endpoints, the intravenous carbetocin group had significantly lower blood loss (n=3 RCTs, MD=-117.74 mL, 95% CI [-185.41, -50.07], p<0.001), need for additional uterotonics (n=2 RCTs, RR=0.06, 95% CI [0.01, 0.46], p=0.007), need for uterine massage (n=2 RCTs, RR=0.40, 95% CI [0.20, 0.80], p=0.009), and need for blood transfusion (n=2 RCTs, RR=0.38, 95% CI [0.15, 0.95], p=0.04) compared with the rectal misoprostol group. Regarding safety endpoints, the rates of diarrhea (n=3 RCTs, RR=0.18, 95% CI [0.06, 0.55], p=0.003) and chills (n=2 RCTs, RR=0.31, 95% CI [0.12, 0.83], p=0.02) were significantly lower in the intravenous carbetocin group compared with the rectal misoprostol group. However, there was no significant difference between both groups regarding the rates of headache (n=3 RCTs, RR=1.23, 95% CI [0.06, 1.91], p=0.35) and facial flushing (n=2 RCTs, RR=0.88, 95% CI [0.46, 1.68], p=0.70). In conclusion, it was discovered that intravenous carbetocin was a superior substitute for rectal misoprostol for the active management of the third stage of labor. With far fewer side effects, intravenous carbetocin decreased postpartum blood loss and further uterotonic use. For women who have a high risk of PPH, intravenous carbetocin is advised.
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Figueira CO, Surita FG, Fertrin K, Nobrega GDM, Costa ML. Main Complications during Pregnancy and Recommendations for Adequate Antenatal Care in Sickle Cell Disease: A Literature Review. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:593-601. [PMID: 35139577 PMCID: PMC9948053 DOI: 10.1055/s-0042-1742314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Sickle cell disease (SCD) is the most common monogenic disease worldwide, with a variable prevalence in each continent. A single nucleotide substitution leads to an amino-acid change in the β-globin chain, altering the normal structure ofhemoglobin, which is then called hemoglobin S inherited in homozygosity (HbSS) or double heterozygosity (HbSC, HbSβ), and leads to chronic hemolysis, vaso-occlusion, inflammation, and endothelium activation. Pregnant women with SCD are at a higher risk of developing maternal and perinatal complications. We performed a narrative review of the literature considering SCD and pregnancy, the main clinical and obstetrical complications, the specific antenatal care, and the follow-up for maternal and fetal surveillance. Pregnant women with SCD are at a higher risk of developing clinical and obstetric complications such as pain episodes, pulmonary complications, infections, thromboembolic events, preeclampsia, and maternal death. Their newborns are also at an increased risk of developing neonatal complications: fetal growth restriction, preterm birth, stillbirth. Severe complications can occur in patients of any genotype. We concluded that SCD is a high-risk condition that increases maternal and perinatal morbidity and mortality. A multidisciplinary approach during pregnancy and the postpartum period is key to adequately diagnose and treat complications.
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Affiliation(s)
| | | | - Kleber Fertrin
- Division of Hematology, Department of Medicine, University of Washington, Seattle, Washington, United States
| | | | - Maria Laura Costa
- Department of Obstetrics and Gynecology, Universidade Estadual de Campinas, Campinas, SP, Brazil
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Gupta S, Pandya S, Jain K, Grewal A, Parikh K, Sharma K, Gupta A, Kasodekar S, Parameswari A, Gogoi D, Raiger L, Rao Ravindra G, Trikha A. The association of obstetric anesthesiologists, India – An expert committee consensus statement and recommendations for the management of maternal cardiac arrest. JOURNAL OF OBSTETRIC ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.4103/joacc.joacc_44_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Johansen LT, Braut GS, Acharya G, Andresen JF, Øian P. Adverse events reporting by obstetric units in Norway as part of their quality assurance and patient safety work: an analysis of practice. BMC Health Serv Res 2021; 21:931. [PMID: 34493278 PMCID: PMC8424984 DOI: 10.1186/s12913-021-06956-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Norwegian Board of Health Supervision aims to contribute to the improvement of quality and patient safety in the healthcare services. Planned audits were performed to investigate how 12 selected Norwegian obstetric units reported and analyzed adverse events as the part of their quality assurance and patient safety work. METHODS Serious adverse events coded as birth asphyxia, shoulder dystocia and severe postpartum hemorrhage that occurred during 2014 (the most recent year for which the quality assured data were available) were obtained from the Medical Birth Registry of Norway. The obstetric units were asked to submit medical records, internal adverse events reports, and their internal guidelines outlining which events should be reported to the quality assurance system. We identified the adverse events at each obstetric unit that were reported internally and/or to the central authorities. Two obstetricians carried out an evaluation of each event reported. RESULTS Five hundred fifty-three serious adverse events were registered among 17,323 births that took place at the selected units. Twenty-one events were excluded because of incorrect coding or missing information. Eight events were registered in more than one category, and these were distributed to the category directly related to injury or adverse outcome. Nine of twelve (75 %) obstetric units had written guidelines describing which events should be reported. The obstetric units reported 49 of 524 (9.3 %) serious adverse events in their internal quality assurance system and 39 (7.4 %) to central authorities. Of the very serious adverse events, 29 of 149 (19.4 %) were reported. Twenty-three of 49 (47 %) reports did not contain relevant assessments or proposals for improving quality and patient safety. CONCLUSIONS This study showed that adverse event reporting and analyses by Norwegian obstetric units, as a part of quality assurance and patient safety work, are suboptimal. The reporting culture and compliance with guidelines need to be improved substantially for better safety in patient care, risk mitigation and clinical quality assurance.
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Affiliation(s)
- Lars T Johansen
- Department for Specialized Health Services, Norwegian Board of Health Supervision, PO Box 231 Skøyen, 0213, Oslo, Norway.
| | - Geir Sverre Braut
- Department for Specialized Health Services, Norwegian Board of Health Supervision, PO Box 231 Skøyen, 0213, Oslo, Norway.,Stavanger University Hospital, Stavanger, Norway.,Western Norway University of Applied Sciences, Sogndal, Norway
| | - Ganesh Acharya
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway.,Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway.,Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology, Karolinska Institute and Center for Fetal Medicine, Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Fredrik Andresen
- Department for Specialized Health Services, Norwegian Board of Health Supervision, PO Box 231 Skøyen, 0213, Oslo, Norway
| | - Pål Øian
- Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
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Gallos I, Williams H, Price M, Pickering K, Merriel A, Tobias A, Lissauer D, Gee H, Tunçalp Ö, Gyte G, Moorthy V, Roberts T, Deeks J, Hofmeyr J, Gülmezoglu M, Coomarasamy A. Uterotonic drugs to prevent postpartum haemorrhage: a network meta-analysis. Health Technol Assess 2020; 23:1-356. [PMID: 30821683 DOI: 10.3310/hta23090] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Prophylactic uterotonic drugs can reduce blood loss and are routinely recommended. There are several uterotonic drugs for preventing PPH, but it is still debatable which drug or combination of drugs is the most effective. OBJECTIVES To identify the most effective and cost-effective uterotonic drug(s) to prevent PPH, and generate a ranking according to their effectiveness and side-effect profile. METHODS The Cochrane Pregnancy and Childbirth's Trials Register (1 June 2015), ClinicalTrials.gov and the World Health Organization (WHO)'s International Clinical Trials Registry Platform (ICTRP) were searched for unpublished trial reports (30 June 2015). In addition, reference lists of retrieved studies (updated October 2017) were searched for randomised trials evaluating uterotonic drugs for preventing PPH. The study estimated relative effects and rankings for preventing PPH, defined as blood loss of ≥ 500 ml and ≥ 1000 ml. Pairwise meta-analyses and network meta-analysis were performed to determine the relative effects and rankings of all available drugs and combinations thereof [ergometrine, misoprostol (Cytotec®; Pfizer Inc., New York, NY, USA), misoprostol plus oxytocin (Syntocinon®; Novartis International AG, Basel, Switzerland), carbetocin (Pabal®; Ferring Pharmaceuticals, Saint-Prex, Switzerland), ergometrine plus oxytocin (Syntometrine®; Alliance Pharma plc, Chippenham, UK), oxytocin, and a placebo or no treatment]. Primary outcomes were stratified according to the mode of birth, prior risk of PPH, health-care setting, drug dosage, regimen and route of drug administration. Sensitivity analyses were performed according to study quality and funding source, among others. A model-based economic evaluation compared the relative cost-effectiveness separately for vaginal births and caesareans with or without including side effects. RESULTS From 137 randomised trials and 87,466 women, ergometrine plus oxytocin, carbetocin and misoprostol plus oxytocin were found to reduce the risk of PPH blood loss of ≥ 500 ml compared with the standard drug, oxytocin [ergometrine plus oxytocin: risk ratio (RR) 0.69, 95% confidence interval (CI) 0.57 to 0.83; carbetocin: RR 0.72, 95% CI 0.52 to 1.00; misoprostol plus oxytocin: RR 0.73, 95% CI 0.6 to 0.9]. Each of these three strategies had 100% cumulative probability of being ranked first, second or third most effective. Oxytocin was ranked fourth, with an almost 0% cumulative probability of being ranked in the top three. Similar rankings were noted for the reduction of PPH blood loss of ≥ 1000 ml (ergometrine plus oxytocin: RR 0.77, 95% CI 0.61 to 0.95; carbetocin: RR 0.70, 95% CI 0.38 to 1.28; misoprostol plus oxytocin: RR 0.90, 95% CI 0.72 to 1.14), and most secondary outcomes. Ergometrine plus oxytocin and misoprostol plus oxytocin had the poorest ranking for side effects. Carbetocin had a favourable side-effect profile, which was similar to oxytocin. However, the analysis was restricted to high-quality studies, carbetocin lost its ranking and was comparable to oxytocin. The relative cost-effectiveness of the alternative strategies is inconclusive, and the results are affected by both the uncertainty and inconsistency in the data reported on adverse events. For vaginal delivery, when assuming no adverse events, ergometrine plus oxytocin is less costly and more effective than all strategies except carbetocin. The strategy of carbetocin is both more effective and more costly than all other strategies. When taking adverse events into consideration, all prevention strategies, except oxytocin, are more costly and less effective than carbetocin. For delivery by caesarean section, with and without adverse events, the relative cost-effectiveness is different, again because of the uncertainty in the available data. LIMITATIONS There was considerable uncertainty in findings within the planned subgroup analyses, and subgroup effects cannot be ruled out. CONCLUSIONS Ergometrine plus oxytocin, carbetocin and misoprostol plus oxytocin are more effective uterotonic drug strategies for preventing PPH than the current standard, oxytocin. Ergometrine plus oxytocin and misoprostol plus oxytocin cause significant side effects. Carbetocin has a favourable side-effect profile, which was similar to oxytocin. However, most carbetocin trials are small and of poor quality. There is a need for a large high-quality trial comparing carbetocin with oxytocin; such a trial is currently being conducted by the WHO. The relative cost-effectiveness is inconclusive, and results are affected by uncertainty and inconsistency in adverse events data. STUDY REGISTRATION This study is registered as PROSPERO CRD42015020005; Cochrane Pregnancy and Childbirth Group (substudy) reference number 0871; PROSPERO-Cochrane (substudy) reference number CRD42015026568; and sponsor reference number ERN_13-1414 (University of Birmingham, Birmingham, UK). FUNDING Funding for this study was provided by the National Institute for Health Research Health Technology Assessment programme in a research award to the University of Birmingham and supported by the UK charity Ammalife (UK-registered charity 1120236). The funders of the study had no role in study design, data collection, data synthesis, interpretation or writing of the report.
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Affiliation(s)
- Ioannis Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Helen Williams
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Malcolm Price
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Karen Pickering
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Abi Merriel
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Aurelio Tobias
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - David Lissauer
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Harry Gee
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Özge Tunçalp
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Gillian Gyte
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Centre for Women's Health Research, Liverpool Women's NHS Foundation Trust, Liverpool, UK.,National Childbirth Trust, London, UK
| | - Vidhya Moorthy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Tracy Roberts
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jonathan Deeks
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Justus Hofmeyr
- Effective Care Research Unit, University of the Witwatersrand/Fort Hare, Eastern Cape Department of Health, East London, South Africa
| | - Metin Gülmezoglu
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Samy A, Ali MK, Abbas AM, Wahab HA, Wali AA, Hussien AH, Mostafa M, Taymour MA, Ogila AI, Ahmad Y, Essam A, Mahmoud M. Randomized controlled trial of the effect of bilateral uterine artery ligation during cesarean among women at risk of uterine atony. Int J Gynaecol Obstet 2020; 148:219-224. [PMID: 31755559 DOI: 10.1002/ijgo.13064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 10/06/2019] [Accepted: 11/20/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess the effectiveness of prophylactic bilateral uterine artery ligation (BUAL) in reducing the incidence of postpartum hemorrhage (PPH) during cesarean delivery among women at risk of uterine atony. METHODS A randomized clinical trial at Cairo University Maternity Hospital, Egypt, from December 2017 to December 2018. Women at risk of uterine atony undergoing scheduled or emergency cesarean were randomized to two groups. In the BUAL group, women underwent BUAL before placental delivery; in the control group, women had cesarean delivery without BUAL. The primary outcome was the estimated blood loss during cesarean. RESULTS Intraoperative blood loss during cesarean was significantly lower in the BUAL group than in the control group (523.4 ± 41.0 vs 619.6 ± 36.1 mL; P=0.003). Blood loss in the first 6 hours after cesarean was also significantly lower in the BUAL group than in the control group (246.1 ± 21.4 vs 326.1 ± 18.5 mL; P=0.006). There was no difference in operative time between the two groups (52.1 ± 6.1 vs 52.2 ± 6.8, P=0.880). CONCLUSION BUAL during cesarean was found to be an effective method for decreasing blood loss during and after cesarean delivery among women at risk of uterine atony and subsequent PPH. CLINICALTRIALS.GOV: NCT03591679.
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Affiliation(s)
- Ahmed Samy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohammed K Ali
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed M Abbas
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Hala A Wahab
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed A Wali
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Aml H Hussien
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mona Mostafa
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohammad A Taymour
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Asmaa I Ogila
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Yahia Ahmad
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Aimy Essam
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mostafa Mahmoud
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Garba Z, Abdullahi HM, Yusuf M, Takai IU, Muhammad ID. Appropriate Documentation of the Timing of Events in the Management of Women with Postpartum Hemorrhage in Aminu Kano Teaching Hospital: A 2-Year Audit. Niger Med J 2019; 60:9-12. [PMID: 31413428 PMCID: PMC6676997 DOI: 10.4103/nmj.nmj_5_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background: Appropriate documentation of the timing of events in the management of women with postpartum hemorrhage (PPH) is associated with better outcome. Objective: To find out how best the Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, fares when compared with the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines about appropriate documentation of the timing of events in the management of PPH. Methodology: It was a retrospective study based on findings obtained from the case folders of women who had PPH between January 2016 and December 2017. A structured pro forma was used to extract information such as personal data, type of PPH, vital signs of patients, sequence of events, administration of pharmacological agents, and timing of interventions. Results: There were 5202 patients who presented to the labor ward, and 129 of them were cases of PPH giving an incidence of 2.48%. The mean age of the patients was 20.38 ± 1.13 years, and about half of them (47.6%) were multiparas. There was appropriate documentation in terms of initial assessment, resuscitation, and investigations as the percentages of standards achieved are 85%, 78.6%, and 85.7%, respectively. Sixty-one percent of the patients had treatment within the time recommended and 56% had treatment with appropriate uterotonics. Appropriate documentation of major surgeries according to the guidelines was achieved in 12% of cases. Conclusion: There was good performance in documentation of initial management of patients with PPH when compared with the RCOG guidelines but suboptimal performance in timing of major surgical interventions.
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Affiliation(s)
- Zainab Garba
- Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Hauwa Musa Abdullahi
- Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Murtala Yusuf
- Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Idris Usman Takai
- Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria
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Gallos ID, Papadopoulou A, Man R, Athanasopoulos N, Tobias A, Price MJ, Williams MJ, Diaz V, Pasquale J, Chamillard M, Widmer M, Tunçalp Ö, Hofmeyr GJ, Althabe F, Gülmezoglu AM, Vogel JP, Oladapo OT, Coomarasamy A. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Cochrane Database Syst Rev 2018; 12:CD011689. [PMID: 30569545 PMCID: PMC6388086 DOI: 10.1002/14651858.cd011689.pub3] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Prophylactic uterotonic agents can prevent PPH, and are routinely recommended. The current World Health Organization (WHO) recommendation for preventing PPH is 10 IU (international units) of intramuscular or intravenous oxytocin. There are several uterotonic agents for preventing PPH but there is still uncertainty about which agent is most effective with the least side effects. This is an update of a Cochrane Review which was first published in April 2018 and was updated to incorporate results from a recent large WHO trial. OBJECTIVES To identify the most effective uterotonic agent(s) to prevent PPH with the least side effects, and generate a ranking according to their effectiveness and side-effect profile. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (24 May 2018), and reference lists of retrieved studies. SELECTION CRITERIA All randomised controlled trials or cluster-randomised trials comparing the effectiveness and side effects of uterotonic agents with other uterotonic agents, placebo or no treatment for preventing PPH were eligible for inclusion. Quasi-randomised trials were excluded. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. DATA COLLECTION AND ANALYSIS At least three review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for preventing PPH ≥ 500 mL and PPH ≥ 1000 mL as primary outcomes. Secondary outcomes included blood loss and related outcomes, morbidity outcomes, maternal well-being and satisfaction and side effects. Primary outcomes were also reported for pre-specified subgroups, stratifying by mode of birth, prior risk of PPH, healthcare setting, dosage, regimen and route of administration. We performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available agents. MAIN RESULTS The network meta-analysis included 196 trials (135,559 women) involving seven uterotonic agents and placebo or no treatment, conducted across 53 countries (including high-, middle- and low-income countries). Most trials were performed in a hospital setting (187/196, 95.4%) with women undergoing a vaginal birth (71.5%, 140/196).Relative effects from the network meta-analysis suggested that all agents were effective for preventing PPH ≥ 500 mL when compared with placebo or no treatment. The three highest ranked uterotonic agents for prevention of PPH ≥ 500 mL were ergometrine plus oxytocin combination, misoprostol plus oxytocin combination and carbetocin. There is evidence that ergometrine plus oxytocin (RR 0.70, 95% CI 0.59 to 0.84, moderate certainty), carbetocin (RR 0.72, 95% CI 0.56 to 0.93, moderate certainty) and misoprostol plus oxytocin (RR 0.70, 95% CI 0.58 to 0.86, low certainty) may reduce PPH ≥ 500 mL compared with oxytocin. Low-certainty evidence suggests that misoprostol, injectable prostaglandins, and ergometrine may make little or no difference to this outcome compared with oxytocin.All agents except ergometrine and injectable prostaglandins were effective for preventing PPH ≥ 1000 mL when compared with placebo or no treatment. High-certainty evidence suggests that ergometrine plus oxytocin (RR 0.83, 95% CI 0.66 to 1.03) and misoprostol plus oxytocin (RR 0.88, 95% CI 0.70 to 1.11) make little or no difference in the outcome of PPH ≥ 1000 mL compared with oxytocin. Low-certainty evidence suggests that ergometrine may make little or no difference to this outcome compared with oxytocin meanwhile the evidence on carbetocin was of very low certainty. High-certainty evidence suggests that misoprostol is less effective in preventing PPH ≥ 1000 mL when compared with oxytocin (RR 1.19, 95% CI 1.01 to 1.42). Despite the comparable relative treatment effects between all uterotonics (except misoprostol) and oxytocin, ergometrine plus oxytocin, misoprostol plus oxytocin combinations and carbetocin were the highest ranked agents for PPH ≥ 1000 mL.Misoprostol plus oxytocin reduces the use of additional uterotonics (RR 0.56, 95% CI 0.42 to 0.73, high certainty) and probably also reduces the risk of blood transfusion (RR 0.51, 95% CI 0.37 to 0.70, moderate certainty) when compared with oxytocin. Carbetocin, injectable prostaglandins and ergometrine plus oxytocin may also reduce the use of additional uterotonics but the certainty of the evidence is low. No meaningful differences could be detected between all agents for maternal deaths or severe morbidity as these outcomes were rare in the included randomised trials where they were reported.The two combination regimens were associated with important side effects. When compared with oxytocin, misoprostol plus oxytocin combination increases the likelihood of vomiting (RR 2.11, 95% CI 1.39 to 3.18, high certainty) and fever (RR 3.14, 95% CI 2.20 to 4.49, moderate certainty). Ergometrine plus oxytocin increases the likelihood of vomiting (RR 2.93, 95% CI 2.08 to 4.13, moderate certainty) and may make little or no difference to the risk of hypertension, however absolute effects varied considerably and the certainty of the evidence was low for this outcome.Subgroup analyses did not reveal important subgroup differences by mode of birth (caesarean versus vaginal birth), setting (hospital versus community), risk of PPH (high versus low risk for PPH), dose of misoprostol (≥ 600 mcg versus < 600 mcg) and regimen of oxytocin (bolus versus bolus plus infusion versus infusion only). AUTHORS' CONCLUSIONS All agents were generally effective for preventing PPH when compared with placebo or no treatment. Ergometrine plus oxytocin combination, carbetocin, and misoprostol plus oxytocin combination may have some additional desirable effects compared with the current standard oxytocin. The two combination regimens, however, are associated with significant side effects. Carbetocin may be more effective than oxytocin for some outcomes without an increase in side effects.
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Affiliation(s)
- Ioannis D Gallos
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Argyro Papadopoulou
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Rebecca Man
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Nikolaos Athanasopoulos
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Aurelio Tobias
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Malcolm J Price
- University of BirminghamSchool of Health and Population SciencesBirminghamUKB15 2TG
| | - Myfanwy J Williams
- University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthLiverpoolUK
| | - Virginia Diaz
- Centro Rosarino de Estudios Perinatales (CREP)Moreno 878, 6to pisoRosarioSanta FeArgentinaS2000DKR
| | - Julia Pasquale
- Centro Rosarino de Estudios Perinatales (CREP)Moreno 878, 6to pisoRosarioSanta FeArgentinaS2000DKR
| | - Monica Chamillard
- Centro Rosarino de Estudios Perinatales (CREP)Moreno 878, 6to pisoRosarioSanta FeArgentinaS2000DKR
| | - Mariana Widmer
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - Özge Tunçalp
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - G Justus Hofmeyr
- Walter Sisulu University, University of Fort Hare, University of the Witwatersrand, Eastern Cape Department of HealthEast LondonSouth Africa
| | | | - Ahmet Metin Gülmezoglu
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - Joshua P Vogel
- Burnet InstituteMaternal and Child Health85 Commercial RoadMelbourneAustralia
| | - Olufemi T Oladapo
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - Arri Coomarasamy
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
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Gallos ID, Williams HM, Price MJ, Merriel A, Gee H, Lissauer D, Moorthy V, Tobias A, Deeks JJ, Widmer M, Tunçalp Ö, Gülmezoglu AM, Hofmeyr GJ, Coomarasamy A. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Cochrane Database Syst Rev 2018; 4:CD011689. [PMID: 29693726 PMCID: PMC6494487 DOI: 10.1002/14651858.cd011689.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Prophylactic uterotonic drugs can prevent PPH, and are routinely recommended. There are several uterotonic drugs for preventing PPH but it is still debatable which drug is best. OBJECTIVES To identify the most effective uterotonic drug(s) to prevent PPH, and generate a ranking according to their effectiveness and side-effect profile. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (1 June 2015), ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) for unpublished trial reports (30 June 2015) and reference lists of retrieved studies. SELECTION CRITERIA All randomised controlled comparisons or cluster trials of effectiveness or side-effects of uterotonic drugs for preventing PPH.Quasi-randomised trials and cross-over trials are not eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS At least three review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for preventing PPH ≥ 500 mL and PPH ≥ 1000 mL as primary outcomes. We performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available drugs. We stratified our primary outcomes according to mode of birth, prior risk of PPH, healthcare setting, dosage, regimen and route of drug administration, to detect subgroup effects.The absolute risks in the oxytocin are based on meta-analyses of proportions from the studies included in this review and the risks in the intervention groups were based on the assumed risk in the oxytocin group and the relative effects of the interventions. MAIN RESULTS This network meta-analysis included 140 randomised trials with data from 88,947 women. There are two large ongoing studies. The trials were mostly carried out in hospital settings and recruited women who were predominantly more than 37 weeks of gestation having a vaginal birth. The majority of trials were assessed to have uncertain risk of bias due to poor reporting of study design. This primarily impacted on our confidence in comparisons involving carbetocin trials more than other uterotonics.The three most effective drugs for prevention of PPH ≥ 500 mL were ergometrine plus oxytocin combination, carbetocin, and misoprostol plus oxytocin combination. These three options were more effective at preventing PPH ≥ 500 mL compared with oxytocin, the drug currently recommended by the WHO (ergometrine plus oxytocin risk ratio (RR) 0.69 (95% confidence interval (CI) 0.57 to 0.83), moderate-quality evidence; carbetocin RR 0.72 (95% CI 0.52 to 1.00), very low-quality evidence; misoprostol plus oxytocin RR 0.73 (95% CI 0.60 to 0.90), moderate-quality evidence). Based on these results, about 10.5% women given oxytocin would experience a PPH of ≥ 500 mL compared with 7.2% given ergometrine plus oxytocin combination, 7.6% given carbetocin, and 7.7% given misoprostol plus oxytocin. Oxytocin was ranked fourth with close to 0% cumulative probability of being ranked in the top three for PPH ≥ 500 mL.The outcomes and rankings for the outcome of PPH ≥ 1000 mL were similar to those of PPH ≥ 500 mL. with the evidence for ergometrine plus oxytocin combination being more effective than oxytocin (RR 0.77 (95% CI 0.61 to 0.95), high-quality evidence) being more certain than that for carbetocin (RR 0.70 (95% CI 0.38 to 1.28), low-quality evidence), or misoprostol plus oxytocin combination (RR 0.90 (95% CI 0.72 to 1.14), moderate-quality evidence)There were no meaningful differences between all drugs for maternal deaths or severe morbidity as these outcomes were so rare in the included randomised trials.Two combination regimens had the poorest rankings for side-effects. Specifically, the ergometrine plus oxytocin combination had the higher risk for vomiting (RR 3.10 (95% CI 2.11 to 4.56), high-quality evidence; 1.9% versus 0.6%) and hypertension [RR 1.77 (95% CI 0.55 to 5.66), low-quality evidence; 1.2% versus 0.7%), while the misoprostol plus oxytocin combination had the higher risk for fever (RR 3.18 (95% CI 2.22 to 4.55), moderate-quality evidence; 11.4% versus 3.6%) when compared with oxytocin. Carbetocin had similar risk for side-effects compared with oxytocin although the quality evidence was very low for vomiting and for fever, and was low for hypertension. AUTHORS' CONCLUSIONS Ergometrine plus oxytocin combination, carbetocin, and misoprostol plus oxytocin combination were more effective for preventing PPH ≥ 500 mL than the current standard oxytocin. Ergometrine plus oxytocin combination was more effective for preventing PPH ≥ 1000 mL than oxytocin. Misoprostol plus oxytocin combination evidence is less consistent and may relate to different routes and doses of misoprostol used in the studies. Carbetocin had the most favourable side-effect profile amongst the top three options; however, most carbetocin trials were small and at high risk of bias.Amongst the 11 ongoing studies listed in this review there are two key studies that will inform a future update of this review. The first is a WHO-led multi-centre study comparing the effectiveness of a room temperature stable carbetocin versus oxytocin (administered intramuscularly) for preventing PPH in women having a vaginal birth. The trial includes around 30,000 women from 10 countries. The other is a UK-based trial recruiting more than 6000 women to a three-arm trial comparing carbetocin, oxytocin and ergometrine plus oxytocin combination. Both trials are expected to report in 2018.Consultation with our consumer group demonstrated the need for more research into PPH outcomes identified as priorities for women and their families, such as women's views regarding the drugs used, clinical signs of excessive blood loss, neonatal unit admissions and breastfeeding at discharge. To date, trials have rarely investigated these outcomes. Consumers also considered the side-effects of uterotonic drugs to be important but these were often not reported. A forthcoming set of core outcomes relating to PPH will identify outcomes to prioritise in trial reporting and will inform futures updates of this review. We urge all trialists to consider measuring these outcomes for each drug in all future randomised trials. Lastly, future evidence synthesis research could compare the effects of different dosages and routes of administration for the most effective drugs.
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Affiliation(s)
- Ioannis D Gallos
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Helen M Williams
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Malcolm J Price
- University of BirminghamSchool of Health and Population SciencesBirminghamUKB15 2TG
| | - Abi Merriel
- University of BristolBristol Medical SchoolDepartment of Women's and Children's HealthThe ChilternsSouthmead HospitalUKBS10 5NB
| | - Harold Gee
- 20 St Agnes RoadMoseleyBirminghamUKB13 9PW
| | - David Lissauer
- University of BirminghamSchool of Clinical and Experimental MedicineC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Vidhya Moorthy
- Sandwell and West Birmingham NHS TrustDepartment of Obstetrics and GynaecologyCity HospitalDudley RoadBirminghamUKB18 7QH
| | - Aurelio Tobias
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Jonathan J Deeks
- University of BirminghamInstitute of Applied Health ResearchEdgbastonBirminghamUKB15 2TT
| | - Mariana Widmer
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - Özge Tunçalp
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - Ahmet Metin Gülmezoglu
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - G Justus Hofmeyr
- Walter Sisulu University, University of the Witwatersrand, Eastern Cape Department of HealthEast LondonSouth Africa
| | - Arri Coomarasamy
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
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12
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Parry Smith WR, Gallos ID, Williams HM, Widmer M, Angolkar M, Tobias A, Price MJ, Alfirevic Z, Weeks A, Hofmeyr GJ, Gülmezoglu AM, Coomarasamy A. First-line uterotonics for treating postpartum haemorrhage: a systematic review and network meta-analysis. Hippokratia 2017. [DOI: 10.1002/14651858.cd012754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- William R Parry Smith
- University of Birmingham; Institute of Metabolism and Systems Research; c/o Academic Unit, 3rd Floor Birmingham Women's Hospital Foundation Trust, Mindelsohn Way Birmingham West Midlands UK B15 2TG
| | - Ioannis D Gallos
- University of Birmingham; Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Helen M Williams
- University of Birmingham; Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Mariana Widmer
- World Health Organization; Department of Reproductive Health and Research; Office X031 Geneva Switzerland 1211
| | - Mubashir Angolkar
- JN Medical College; Women's and Children's Health Research; Nehru Nagar Belgaum Karnataka India 590010
| | - Aurelio Tobias
- University of Birmingham; Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Malcolm J Price
- University of Birmingham; School of Health and Population Sciences; Birmingham UK B15 2TG
| | - Zarko Alfirevic
- The University of Liverpool; Department of Women's and Children's Health; First Floor, Liverpool Women's NHS Foundation Trust Crown Street Liverpool UK L8 7SS
| | - Andrew Weeks
- The University of Liverpool; Department of Women's and Children's Health; First Floor, Liverpool Women's NHS Foundation Trust Crown Street Liverpool UK L8 7SS
| | - G Justus Hofmeyr
- Walter Sisulu University, University of the Witwatersrand, Eastern Cape Department of Health; East London South Africa
| | - A Metin Gülmezoglu
- World Health Organization; UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research; 20 Avenue Appia Geneva Switzerland 1211
| | - Arri Coomarasamy
- University of Birmingham; Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
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Battaloglu E, Porter K. Management of pregnancy and obstetric complications in prehospital trauma care: prehospital resuscitative hysterotomy/perimortem caesarean section. Emerg Med J 2017; 34:326-330. [PMID: 28270448 DOI: 10.1136/emermed-2016-205979] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 01/12/2017] [Accepted: 01/25/2017] [Indexed: 11/03/2022]
Abstract
The need for prehospital resuscitative hysterotomy/perimortem caesarean section is rare. The procedures can be daunting and clinically challenging for practitioners. Maternal death can be averted by swift and decisive action. This guideline serves to inform prehospital practitioners about conducting maternal resuscitation following cardiac arrest, provides an evidence-based framework to support decision making and highlights areas for improvement in prehospital care.
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Affiliation(s)
- Emir Battaloglu
- Academic Department of Clinical Traumatology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Keith Porter
- Academic Department of Clinical Traumatology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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14
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Rani PR, Begum J. Recent Advances in the Management of Major Postpartum Haemorrhage - A Review. J Clin Diagn Res 2017; 11:QE01-QE05. [PMID: 28384942 DOI: 10.7860/jcdr/2017/22659.9463] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 10/25/2016] [Indexed: 11/24/2022]
Abstract
Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and morbidity worldwide and 75-90% of these haemorrhage results from uterine atony. Delayed and substandard obstetrics care can kill a woman within hours of Major Obstetric Haemorrhage (MOH). Prenatal identification of at risk women, prompt assessment of blood loss, effective management and involvement of multidisciplinary teams is of utmost importance to save the lives of these women. However, even with the best prenatal care, PPH occurs, it can occur without any risk factors. The first step in management is achieving haemodynamic stability, second being arrest of bleeding, both are done simultaneously. Cases of refractory PPH is managed by postpartum hysterectomy which results in complete inability in hosting a future pregnancy, a psychological impact and risk of intra operative surgical morbidities. This review discusses the current evidence based management of PPH, existing controversies in transfusion of blood and blood products and newer advances in this field. It was conducted by searching the English language medical literature using Medline (1994-2015). The current scenario in developing countries mandates research on newer and practicable strategies to tackle PPH which can be implemented effectively and have an upper edge over the existing practices in the management of PPH.
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Affiliation(s)
- P Reddi Rani
- Professor, Department of Obstetrics and Gynaecology, Mahatama Gandhi Medical College and Research , Pillaiyarkuppam, Puducherry, India
| | - Jasmina Begum
- Associate Professor, Department of Obstetrics and Gynaecology, Mahatama Gandhi Medical College and Research , Pillaiyarkuppam, Puducherry, India
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Pearson GA, Pepper W, Russell R, MacKenzie IZ. Retrospective study to investigate the possible relationship between excess blood loss at caesarean section and reduced intra-operative oxytocin dose. Eur J Obstet Gynecol Reprod Biol 2015; 196:31-7. [PMID: 26656199 DOI: 10.1016/j.ejogrb.2015.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/22/2015] [Accepted: 10/28/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To investigate a possible relationship between the oxytocin dose at caesarean section and blood loss. STUDY DESIGN Retrospective analysis of computerised data for all caesarean sections in a UK maternity unit delivering 6000 women annually during 1995-2009 and thus for seven years before and after the 2001 recommended change in oxytocin dose. Validation of computerised and hand-checked clinical data for 1996 and 2006 was performed and annual frequency of blood loss >1000 ml was observed. RESULTS Validation showed most variables recorded were similar for both acquisition methods. For 17,405 (98.9%) caesarean sections with blood loss recorded, excess or severe loss occurred in 127 (1.6%) of 7177 cases during 1995-2001 compared with 362 (4.0%) of 9035 during 2003-2009 (OR 2.317, CI 1.888-2.843). It was significantly more frequent with multiple than singleton pregnancies (OR 1.946, CI 1.417-2.673), with general than neuraxial anaesthesia (OR 4.296, CI 3.479-5.305) and with non-longitudinal than longitudinal fetal lie (OR 1.942, CI 1.501-2.512). Excluding these three groups, excess blood loss was still more frequent during 2003-2009 than 1995-2001 (OR 3.181, CI 2.374-4.263). Oxytocin given during labour did not influence the frequency of excess blood loss. CONCLUSIONS The increased rate of excess blood loss at caesarean section during the latter period could be the result of the reduced oxytocin dose. If similar observations are made by others, this possible relationship should be investigated with appropriate objective randomised studies.
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Affiliation(s)
- Greg A Pearson
- Department of O & G, Derriford Hospital, Plymouth PL6 8DH, United Kingdom
| | - Warwick Pepper
- Department of Anaesthetics, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
| | - Robin Russell
- Department of Anaesthetics, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
| | - I Z MacKenzie
- Nuffield Department of O & G, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom.
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Oliveira LC, da Costa AAR. Maternal near miss in the intensive care unit: clinical and epidemiological aspects. Rev Bras Ter Intensiva 2015; 27:220-7. [PMID: 26270856 PMCID: PMC4592115 DOI: 10.5935/0103-507x.20150033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 05/25/2015] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To analyze the epidemiological clinical profile of women with maternal near miss according to the new World Health Organization criteria. METHODS A descriptive cross-sectional study was conducted, in which the records of patients admitted to the obstetric intensive care unit of a tertiary hospital in Recife (Brazil) over a period of four years were analyzed. Women who presented at least one near miss criterion were included. The variables studied were age, race/color, civil status, education, place of origin, number of pregnancies and prenatal consultations, complications and procedures performed, mode of delivery, gestational age at delivery, and maternal near miss criteria. The descriptive analysis was performed using the program Epi-Info 3.5.1. RESULTS Two hundred fifty-five cases of maternal near miss were identified, with an overall ratio of maternal near miss of 12.8/1,000 live births. Among these cases, 43.2% of the women had incomplete primary education, 44.7% were primiparous, and 20.5% had undergone a previous cesarean section. Regarding specific diagnoses, there was a predominance of hypertensive disorders (62.7%), many of which were complicated by HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome (41.2%). The laboratory near miss criteria were the most often observed (59.6%), due mainly to the high frequency of acute thrombocytopenia (32.5%). CONCLUSIONS A high frequency of women who had a low level of education and who were primiparous was observed. According to the new criteria proposed by the World Health Organization, hypertensive pregnancy disorders are still the most common among maternal near miss cases. The high frequency of HELLP syndrome was also striking, which contributed to acute thrombocytopenia being the most frequent near miss criterion.
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Affiliation(s)
- Leonam Costa Oliveira
- Postgraduate Education Unit in Mother and Child Health,
Instituto de Medicina Integral Professor Fernando Figueira - Recife (PE), Brazil
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18
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Gallos ID, Williams HM, Price MJ, Merriel A, Gee H, Lissauer D, Moorthy V, Tunçalp Ö, Gülmezoglu AM, Deeks JJ, Hofmeyr GJ, Coomarasamy A. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Hippokratia 2015. [DOI: 10.1002/14651858.cd011689] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Ioannis D Gallos
- University of Birmingham; School of Clinical and Experimental Medicine; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Helen M Williams
- University of Birmingham; School of Clinical and Experimental Medicine; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Malcolm J Price
- University of Birmingham; School of Health and Population Sciences; Birmingham UK B15 2TG
| | - Abi Merriel
- University of Birmingham; School of Clinical and Experimental Medicine; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Harold Gee
- 20 St Agnes Road Moseley Birmingham UK B13 9PW
| | - David Lissauer
- University of Birmingham; School of Clinical and Experimental Medicine; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Vidhya Moorthy
- Sandwell and West Birmingham NHS Trust; Department of Obstetrics and Gynaecology; City Hospital Dudley Road Birmingham UK B18 7QH
| | - Özge Tunçalp
- World Health Organization; UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research; 20 Avenue Appia Geneva Switzerland 1211
| | - A Metin Gülmezoglu
- World Health Organization; UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research; 20 Avenue Appia Geneva Switzerland 1211
| | - Jonathan J Deeks
- University of Birmingham; Public Health, Epidemiology and Biostatistics; Edgbaston Birmingham UK B15 2TT
| | - G Justus Hofmeyr
- University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health; Department of Obstetrics and Gynaecology, East London Hospital Complex; Frere and Cecilia Makiwane Hospitals Private Bag X 9047 East London Eastern Cape South Africa 5200
| | - Arri Coomarasamy
- University of Birmingham; School of Clinical and Experimental Medicine; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
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Furuta M, Sandall J, Cooper D, Bick D. Severe maternal morbidity and breastfeeding outcomes in the early post-natal period: a prospective cohort study from one English maternity unit. MATERNAL AND CHILD NUTRITION 2015; 12:808-25. [PMID: 25720327 DOI: 10.1111/mcn.12176] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Previous research has identified potential issues of establishing and maintaining breastfeeding among women who experience severe maternal morbidity associated with pregnancy and birth, but evidence in the UK maternity population was scarce. We explored the association between severe maternal morbidity and breastfeeding outcomes (uptake and prevalence of partial and exclusive breastfeeding) at 6 to 8 weeks post-partum in a UK sample. Data on breastfeeding outcomes were obtained from a large cohort study of women who gave birth in one maternity unit in England to assess the impact of women's experiences of severe maternal morbidity (defined as major obstetric haemorrhage, severe hypertensive disorder or high dependency unit/intensive care unit admission) on their post-natal health and other important outcomes including infant feeding. Results indicated that among women who responded (n = 1824, response rate = 53%), there were no statistically significant differences in breastfeeding outcomes between women who did or did not experience severe morbidity, except for women with severe hypertensive disorder who were less likely to breastfeed either partially or exclusively at 6 to 8 weeks post-partum. Rather, breastfeeding outcomes were related to multi-dimensional factors including sociodemographic (age, ethnicity, living arrangement), other pregnancy outcomes (neonatal intensive care unit admission, mode of birth, women's perceived control during birth) and post-natal psychological factors (depressive symptoms). Women who experience severe maternal morbidity can be reassured that establishing successful breastfeeding can be achieved. More studies are required to understand what support is best for women who have complex health/social needs to establish breastfeeding.
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Affiliation(s)
- Marie Furuta
- Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Jane Sandall
- School of Medicine, King's College London, Women's Health Academic Centre KHP, St. Thomas' Hospital, London, UK
| | - Derek Cooper
- Florence Nightingale School of Nursing and Midwifery, King's College London, London, UK
| | - Debra Bick
- Florence Nightingale School of Nursing and Midwifery, King's College London, London, UK
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Bhattacharyya S, Srivastava A, Knight M. Developing a framework to review near-miss maternal morbidity in India: a structured review and key stakeholder analysis. BMC Health Serv Res 2014; 14:553. [PMID: 25391999 PMCID: PMC4232644 DOI: 10.1186/s12913-014-0553-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 10/24/2014] [Indexed: 11/10/2022] Open
Abstract
Background In India there is a thrust towards promoting institutional delivery, resulting in problems of overcrowding and compromise to quality of care. Review of near-miss obstetric events has been suggested to be useful to investigate health system functioning, complementing maternal death reviews. The aim of this project was to identify the key elements required for a near-miss review programme for India. Methods A structured review was conducted to identify methods used in assessing near-miss cases. The findings of the structured review were used to develop a suggested framework for conducting near-miss reviews in India. A pool of experts in near-miss review methods in low and middle income countries (LMICs) was identified for vetting the framework developed. Opinions were sought about the feasibility of implementing near-miss reviews in India, the processes to be followed, factors that made implementation successful and the associated challenges. A draft of the framework was revised based on the experts’ opinions. Results Five broad methods of near-miss case review/audit were identified: Facility-based near-miss case review, confidential enquiries, criterion-based clinical audit, structured case review (South African Model) and home-based interviews. The opinion of the 11 stakeholders highlighted that the methods that a facility adopts should depend on the type and number of cases the facility handles, availability and maintenance of a good documentation system, and local leadership and commitment of staff. A proposed framework for conducting near-miss reviews was developed that included a combination of criterion-based clinical audit and near-miss review methods. Conclusion The approach allowed for development of a framework for researchers and planners seeking to improve quality of maternal care not only at the facility level but also beyond, encompassing community health workers and referral. Further work is needed to evaluate the implementation of this framework to determine its efficacy in improving the quality of care and hence maternal and perinatal morbidity and mortality.
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Ortiz SR, Perez RA, Hernandez RS, Castorena MIY, Cristobal FGL, Gonzalez MAC, Gallos ID, Coomarasamy A. WITHDRAWN: Carbetocin versus oxytocin for prevention of postpartum hemorrhage: a randomised controlled trial. Eur J Obstet Gynecol Reprod Biol 2014:S0301-2115(14)00478-3. [PMID: 25266913 DOI: 10.1016/j.ejogrb.2014.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 09/03/2014] [Indexed: 11/23/2022]
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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Affiliation(s)
- Sergio Rosales Ortiz
- Medical Unit of High Specialty Hospital of Gynaecology and Obstetrics Luis Castelazo Ayala, Mexican Social Security Institute (IMSS), Mexico City, Mexico
| | - Rogelio Aguado Perez
- Medical Unit of High Specialty Hospital of Gynaecology and Obstetrics Luis Castelazo Ayala, Mexican Social Security Institute (IMSS), Mexico City, Mexico
| | - Roberto Sánchez Hernandez
- Medical Unit of High Specialty Hospital of Gynaecology and Obstetrics Luis Castelazo Ayala, Mexican Social Security Institute (IMSS), Mexico City, Mexico
| | - Maria Inés Yt Castorena
- Medical Unit of High Specialty Hospital of Gynaecology and Obstetrics Luis Castelazo Ayala, Mexican Social Security Institute (IMSS), Mexico City, Mexico
| | - Flor Gabriela Lucas Cristobal
- Medical Unit of High Specialty Hospital of Gynaecology and Obstetrics Luis Castelazo Ayala, Mexican Social Security Institute (IMSS), Mexico City, Mexico
| | - Miriam Azenet Carbajal Gonzalez
- Medical Unit of High Specialty Hospital of Gynaecology and Obstetrics Luis Castelazo Ayala, Mexican Social Security Institute (IMSS), Mexico City, Mexico
| | - Ioannis D Gallos
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham Women's Hospital, Birmingham B15 2TG, UK.
| | - Arri Coomarasamy
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham Women's Hospital, Birmingham B15 2TG, UK
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Pacheco AJC, Katz L, Souza ASR, de Amorim MMR. Factors associated with severe maternal morbidity and near miss in the São Francisco Valley, Brazil: a retrospective, cohort study. BMC Pregnancy Childbirth 2014; 14:91. [PMID: 24576223 PMCID: PMC3943583 DOI: 10.1186/1471-2393-14-91] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 02/21/2014] [Indexed: 12/01/2022] Open
Abstract
Background Maternal mortality remains a major public health issue worldwide, with persistent high rates prevailing principally in underdeveloped countries. The objective of this study was to determine the risk factors for severe maternal morbidity and near miss (SMM/NM) in pregnant and postpartum women at the maternity ward of the Dom Malan Hospital, Petrolina, in northeastern Brazil. Methods A retrospective, cohort study was conducted to evaluate the sociodemographic and obstetric characteristics of the women. Patients who remained hospitalized at the end of the study period were excluded. Risk ratios (RR) and their respective 95% confidence intervals (95% CI) were calculated as a measure of relative risk. Hierarchical multiple logistic regression was also performed. Two-tailed p-values were used for all the tests and the significance level adopted was 5%. Results A total of 2,291 pregnant or postpartum women receiving care between May and August, 2011 were included. The frequencies of severe maternal morbidity and near miss were 17.5% and 1.0%, respectively. Following multivariate analysis, the factors that remained significantly associated with an increased risk of SMM/NM were a Cesarean section in the current pregnancy (OR: 2.6; 95% CI: 2.0 – 3.3), clinical comorbidities (OR: 3.4; 95% CI: 2.5 – 4.4), having attended fewer than six prenatal visits (OR: 1.1; 95% CI: 1.01 – 1.69) and the presence of the third delay (i.e. delay in receiving care at the health facility) (OR: 13.3; 95% CI: 6.7 – 26.4). Conclusions The risk of SMM/NM was greater in women who had been submitted to a Cesarean section in the current pregnancy, in the presence of clinical comorbidities, fewer prenatal visits and when the third delay was present. All these factors could be minimized by initiating a broad debate on healthcare policies, introducing preventive measures and improving the training of the professionals and services providing obstetric care.
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Affiliation(s)
| | - Leila Katz
- Postgraduate Program, Instituto de Medicina Integral Prof, Fernando Figueira (IMIP), Rua dos Coelhos, 300, Boa Vista, 50,070-902 Recife, PE, Brazil.
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Merrick K, Jibodu OA, Rajesh U. The difficult PPH: experience of combined use of B-Lynch brace suture and intrauterine Bakri balloon in York hospital, UK. J OBSTET GYNAECOL 2014; 33:314-5. [PMID: 23550872 DOI: 10.3109/01443615.2012.761184] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- K Merrick
- Department of Obstetrics and Gynaecology, York Teaching Hospital NHS Foundation Trust, York, UK
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The prevalence of severe maternal morbidity and near miss and associated factors in Sergipe, Northeast Brazil. BMC Pregnancy Childbirth 2014; 14:25. [PMID: 24433516 PMCID: PMC3898239 DOI: 10.1186/1471-2393-14-25] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 01/06/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The investigation of severe maternal morbidity (SAMM) and maternal near miss (NM) and associated risk factors is important for the global reduction of maternal mortality. This study investigated the prevalence of SAMM and NM cases and the associated risk factors in two reference maternity hospitals in a capital city in Northeast-Brazil. METHODS A cross-sectional study with a nested case-control component was conducted from June-2011 to May-2012. Case identification was prospective and data collection was performed according to WHO criteria and definitions. Odds ratio with confidence intervals and multivariate analysis were used whenever possible. RESULTS There were 16,243 deliveries, 1,102 SAMM cases, 77 NM cases and 17 maternal deaths. The maternal NM outcome ratio was 5.8 cases/1,000 live births (LB); the total prevalence of SAMM + NM was 72.6 cases/1,000 LB, the maternal near miss: mortality ratio was 4.5cases/1 maternal death (18% of mortality index). Management-based criteria were the most common events for NM (87.1%) and hypertensive disorders for SAMM (67.5%). Higher age, previous abortion and caesarean delivery, the non-adhesion to antenatal care, current caesarean delivery and bad perinatal results were associated with SAMM/NM. In the multivariate analysis, patient's status, previous caesarian and abortion and level of consciousness were significant when analyzed together. CONCLUSIONS SAMM and NM situations were prevalent in the studied population and some risk factors seem to be associated with the event, particularly previous gestational antecedents. Protocols based on SAMM/NM situations can save lives and decrease maternal mortality.
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Allard S, Green L, Hunt BJ. How we manage the haematological aspects of major obstetric haemorrhage. Br J Haematol 2013; 164:177-88. [PMID: 24383841 DOI: 10.1111/bjh.12605] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Major obstetric haemorrhage (MOH) remains an important medical challenge worldwide, contributing to significant maternal morbidity and mortality. Prompt and appropriate management is essential if we are to improve outcomes and reduce substandard care that may result in adverse consequences. This review describes the current understanding of the pathophysiological aspects of MOH together with the principles of transfusion and haemostatic therapy, with emphasis on a coordinated multidisciplinary approach. We also highlight the current lack of evidence available from randomized controlled trials to inform best practice and the need to prioritize research in this key clinical area.
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Affiliation(s)
- Shubha Allard
- Barts Health NHS Trust & NHS Blood and Transplant, London, UK
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Oliveira LC, Costa AARD. Fetal and neonatal deaths among cases of maternal near miss. Rev Assoc Med Bras (1992) 2013; 59:487-94. [PMID: 24080346 DOI: 10.1016/j.ramb.2013.08.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 03/10/2013] [Accepted: 08/26/2013] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To determine the prevalence of fetal and neonatal deaths among patients with maternal near miss and the factors associated with this fatal outcome. METHODS The authors conducted a descriptive, cross-sectional, analyzing medical records of patients admitted to the ICU of a tertiary obstetric Recife (Brazil), between January 2007 and December 2010, who had at least one criterion of near miss defined by WHO. Statistical analysis was performed with Epi-Info 3.3.2, using chi-square and Fisher's exact test, considering a significance level of 5%. For multivariate analysis was constructed as a hierarchical model with the response variable fetal and neonatal deaths. RESULTS We included 246 cases of maternal near miss. Among women in the study, hypertensive disorders occurred in 62.7% to 41.2% in HELLP syndrome and the laboratory criteria for near miss in 59.6%. There were 48 (19.5%) stillbirths and 19 (7.7%) neonatal deaths. After analyzing the variables that remained statistically associated with fetal and neonatal deaths were: severe preeclampsia, placental abruption, endometritis, cesarean delivery, prematurity and the laboratory criteria for maternal near miss. CONCLUSION The high incidence of fetal and neonatal deaths among patients with maternal near miss. Among these women there is an overlap of factors contributing to this fatal outcome, in our study, those who had severe preeclampsia, placental abruption, endometritis, premature birth or laboratory criteria positively associated with deaths.
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Affiliation(s)
- Leonam Costa Oliveira
- Unidade de ensino de pós-graduação em Saúde Materno Infantil, Instituto de Medicina Integral Prof. Fernando Figueira, Recife, PE, Brasil.
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Nakamura-Pereira M, Mendes-Silva W, Dias MAB, Reichenheim ME, Lobato G. Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH-SUS): uma avaliação do seu desempenho para a identificação do near miss materno. CAD SAUDE PUBLICA 2013; 29:1333-45. [DOI: 10.1590/s0102-311x2013000700008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Accepted: 02/25/2013] [Indexed: 11/22/2022] Open
Abstract
Este estudo avaliou o desempenho do Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH-SUS) na identificação de casos de near miss materno ocorridos em hospital do Rio de Janeiro, em 2008. Os casos foram captados pela revisão de todos os prontuários médicos de gestantes ou puérperas internadas na unidade, e a busca por potenciais eventos de near miss na base do SIH-SUS valeu-se de uma lista de procedimentos e códigos da Classificação Internacional de Doenças, 10ª revisão (CID-10), que fossem compatíveis com esse diagnóstico. A revisão de prontuários identificou 27 casos, enquanto na base do SIH-SUS encontrou-se 70 possíveis ocorrências de near miss. Porém, dessas 70 apenas cinco efetivamente eram casos near miss conforme os prontuários, correspondendo então à sensibilidade de 18,5% (IC95%: 6,3-38,1), especificidade de 94,3% (IC95%: 92,8-95,6), área sob a curva ROC de 0,56 (IC95%: 0,48-0,63) e valor preditivo positivo de 10,1% (IC95%: 4,7-20,3). Esses achados sugerem que o SIH-SUS não é adequado para o monitoramento dos casos de near miss materno.
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Lobato G, Nakamura-Pereira M, Mendes-Silva W, Dias MA, Reichenheim ME. Comparing different diagnostic approaches to severe maternal morbidity and near-miss: a pilot study in a Brazilian tertiary hospital. Eur J Obstet Gynecol Reprod Biol 2013. [DOI: 10.1016/j.ejogrb.2012.10.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tayler-Smith K, Zachariah R, Manzi M, Van den Boogaard W, Nyandwi G, Reid T, Van den Bergh R, De Plecker E, Lambert V, Nicolai M, Goetghebuer S, Christaens B, Ndelema B, Kabangu A, Manirampa J, Harries AD. Achieving the millennium development goal of reducing maternal mortality in rural Africa: an experience from Burundi. Trop Med Int Health 2012; 18:166-74. [PMID: 23163431 DOI: 10.1111/tmi.12022] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To estimate the reduction in maternal mortality associated with the emergency obstetric care provided by Médecins Sans Frontières (MSF) and to compare this to the fifth Millennium Development Goal of reducing maternal mortality. METHODS The impact of MSF's intervention was approximated by estimating how many deaths were averted among women transferred to and treated at MSF's emergency obstetric care facility in Kabezi, Burundi, with a severe acute maternal morbidity. Using this estimate, the resulting theoretical maternal mortality ratio in Kabezi was calculated and compared to the Millennium Development Goal for Burundi. RESULTS In 2011, 1385 women from Kabezi were transferred to the MSF facility, of whom 55% had a severe acute maternal morbidity. We estimated that the MSF intervention averted 74% (range 55-99%) of maternal deaths in Kabezi district, equating to a district maternal mortality rate of 208 (range 8-360) deaths/100,000 live births. This lies very near to the 2015 MDG 5 target for Burundi (285 deaths/100,000 live births). CONCLUSION Provision of quality emergency obstetric care combined with a functional patient transfer system can be associated with a rapid and substantial reduction in maternal mortality, and may thus be a possible way to achieve Millennium Development Goal 5 in rural Africa.
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Affiliation(s)
- K Tayler-Smith
- Medecins sans Frontieres, Medical Department (Operational Research), Operational Centre Brussels, MSF-Luxembourg, Luxembourg.
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L Barrett H, Devin R, Clarke S, Dekker Nitert M, Boots R, Fagermo N, K Callaway L, Lust K. A fifteen-year retrospective review of obstetric patients requiring critical care. Obstet Med 2012; 5:166-170. [PMID: 30705698 DOI: 10.1258/om.2012.120033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2012] [Indexed: 11/18/2022] Open
Abstract
Background Maternal mortality is a rare occurrence in developed nations. Given the low maternal mortality rate, other markers must be used to assess maternal risk and quality of obstetric care. One such is admission to critical care. Aims To determine the rate of admission, diagnosis and management of women from conception and up to 6 weeks postpartum to critical care units including coronary care (CCU), high dependency unit (HDU) and intensive care units (ICU). Methods We performed a retrospective review of obstetric patients requiring critical care admission from January 1995 to August 2010. Demographic details, obstetric history, place of admission (CCU, HDU or ICU) and fetal/neonatal outcomes were examined as were initial indication for critical care admission, final diagnosis and treatment administered. Results Data were available from 308 admission incidents. There were 259 (84%) admissions to ICU and 49 (15.9%) to CCU. More than a third of women were transferred from another institution. Those women transferred were more unwell and had a higher mortality rate than local women. Primary diagnoses: obstetric haemorrhage (ICU 30.9%), hypertensive disorders of pregnancy (ICU 16.2%, CCU 12.2%), infection (ICU 14.2%, CCU 6.1%), pre-existing cardiac disease (ICU 9.3%, CCU 55.1%). Conclusions The obstetric population represents only a small percentage of critical care utilisation and overall morbidity and mortality. However, this population is an important and growing group. Increased surveillance peripartum in a critical care facility allows earlier detection of maternal compromise and detailed management. Analysis of these 'near misses' in obstetrics aims to improve pregnancy outcomes.
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Affiliation(s)
- Helen L Barrett
- Internal Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,School of Medicine, University of Queensland, Herston, QLD, 4029, Australia.,UQ Center for Clinical Research, University of Queensland, Herston, QLD, 4029, Australia
| | - Ruth Devin
- Internal Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia
| | - Sophie Clarke
- Internal Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia
| | - Marloes Dekker Nitert
- School of Medicine, University of Queensland, Herston, QLD, 4029, Australia.,UQ Center for Clinical Research, University of Queensland, Herston, QLD, 4029, Australia
| | - Robert Boots
- Intensive Care, Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia
| | - Narelle Fagermo
- Internal Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,School of Medicine, University of Queensland, Herston, QLD, 4029, Australia
| | - Leonie K Callaway
- Internal Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,School of Medicine, University of Queensland, Herston, QLD, 4029, Australia
| | - Karin Lust
- Internal Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,School of Medicine, University of Queensland, Herston, QLD, 4029, Australia
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Severe maternal morbidity during childbirth hospitalisation: a comparative analysis between the Republic of Ireland and Australia. Eur J Obstet Gynecol Reprod Biol 2012; 163:148-53. [DOI: 10.1016/j.ejogrb.2012.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 04/02/2012] [Accepted: 05/01/2012] [Indexed: 11/20/2022]
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Quteitat A, Shraideh I, Malek AMA, Gowieri A, Alnashash H, Amarin ZO. Maternal morbidity: results of a country-wide review. Arch Gynecol Obstet 2012; 286:1357-62. [DOI: 10.1007/s00404-012-2458-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 07/03/2012] [Indexed: 10/28/2022]
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PEACOCK LINZI, CLARK VICKI, CATLING SUE. Recent developments in the obstetric use of cell salvage. ACTA ACUST UNITED AC 2012. [DOI: 10.1111/j.1778-428x.2012.01160.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Su LL, Chong YS. Massive obstetric haemorrhage with disseminated intravascular coagulopathy. Best Pract Res Clin Obstet Gynaecol 2012; 26:77-90. [DOI: 10.1016/j.bpobgyn.2011.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 10/19/2011] [Indexed: 10/15/2022]
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Zanconato G, Cavaliere E, Iacovella C, Vassanelli A, Schweiger V, Cipriani S, Franchi M. Severe maternal morbidity in a tertiary care centre of northern Italy: a 5-year review. J Matern Fetal Neonatal Med 2011; 25:1025-8. [PMID: 21854133 DOI: 10.3109/14767058.2011.614655] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess prevalence and causes of severe acute maternal morbidity cases and evaluate their impact on feto-maternal wellbeing and on facility resources. STUDY DESIGN Observational retrospective study adopting management-based criteria in a tertiary care public hospital during a 5-year period. Criteria adopted were: intensive care unit admission, blood transfusion ≥ 4 units, emergency peripartum hysterectomy and arterial embolization at any time during pregnancy. RESULTS A total of 80 cases were identified, most of them (97.5%) through a combination of two criteria, ICU admission and blood transfusion. Commonest severe obstetric morbidities were major obstetric haemorrhage (48.8%) and hypertensive disorders (27.5%). Immigrant status (OR 1.68, 95% CI 1.03-2.7), pre-term birth (OR 4.15, 95% CI 2.5-6.8), Caesarean section (OR 7.74,95% CI 4.2-14.3) were factors significantly associated with SAMM cases. Major abdominal surgery was necessary in 26 women (32.5%), with emergency peripartum hysterectomy in 11 (13.5%). These events led to an average blood consumption per woman of 6.5 ± 12.8 units and a mean hospital stay of 8.9 ± 5.0 days, significantly longer (p < 0.001) than the average duration of post-delivery care. Maternal mortality to morbidity ratio was 1:80. CONCLUSIONS An integrated intervention-based approach proved to be effective in finding severe acute maternal morbidity cases. Information on underlying causes and associated risk factors may improve prevention and treatment of obstetric morbidities, thus reducing feto-maternal adverse effects and hospital expenditures.
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Affiliation(s)
- Giovanni Zanconato
- University of Verona, Department of Life Science and Reproduction, Verona, Italy.
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van den Akker T, van Rhenen J, Mwagomba B, Lommerse K, Vinkhumbo S, van Roosmalen J. Reduction of severe acute maternal morbidity and maternal mortality in Thyolo District, Malawi: the impact of obstetric audit. PLoS One 2011; 6:e20776. [PMID: 21677788 PMCID: PMC3109003 DOI: 10.1371/journal.pone.0020776] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 05/11/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Critical incident audit and feedback are recommended interventions to improve the quality of obstetric care. To evaluate the effect of audit at district level in Thyolo, Malawi, we assessed the incidence of facility-based severe maternal complications (severe acute maternal morbidity (SAMM) and maternal mortality) during two years of audit and feedback. METHODOLOGY/PRINCIPAL FINDINGS Between September 2007 and September 2009, we included all cases of maternal mortality and SAMM that occurred in Thyolo District Hospital, the main referral facility in the area, using validated disease-specific criteria. During two- to three-weekly audit sessions, health workers and managers identified substandard care factors. Resulting recommendations were implemented and followed up. Feedback was given during subsequent sessions. A linear regression analysis was performed on facility-based severe maternal complications. During the two-year study period, 386 women were included: 46 died and 340 sustained SAMM, giving a case fatality rate of 11.9%. Forty-five cases out of the 386 inclusions were audited in plenary with hospital staff. There was a reduction of 3.1 women with severe maternal complications per 1000 deliveries in the district health facilities, from 13.5 per 1000 deliveries in the beginning to 10.4 per 1000 deliveries at the end of the study period. The incidence of uterine rupture and major obstetric hemorrhage reduced considerably (from 3.5 to 0.2 and from 5.9 to 2.6 per 1000 facility deliveries respectively). CONCLUSIONS Our findings indicate that audit and feedback have the potential to reduce serious maternal complications including maternal mortality. Complications like major hemorrhage and uterine rupture that require relatively straightforward intrapartum emergency management are easier to reduce than those which require uptake of improved antenatal care (eclampsia) or timely intravenous medication or HIV-treatment (peripartum infections).
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Peacock L, Clark V. Cell Salvage in obstetrics: a review of data from the 2007 Scottish Confidential Audit of Severe Maternal Morbidity. Int J Obstet Anesth 2011; 20:196-8. [PMID: 21414771 DOI: 10.1016/j.ijoa.2010.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2010] [Accepted: 12/14/2010] [Indexed: 10/18/2022]
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Lori JR, Starke AE. A critical analysis of maternal morbidity and mortality in Liberia, West Africa. Midwifery 2011; 28:67-72. [PMID: 21232836 DOI: 10.1016/j.midw.2010.12.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2010] [Revised: 11/28/2010] [Accepted: 12/01/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To conduct a secondary analysis of maternal death and near-miss audits conducted at the community and facility level to explore the causes and circumstances surrounding maternal mortality and severe morbidity in one rural county in Liberia, West Africa. DESIGN A non-experimental, descriptive design utilising maternal death and near-miss audit surveys was utilised for data collection. Thaddeus and Maine's Three Delays Model was used as a framework for analysis. SETTING One rural county in north-central Liberia. PARTICIPANTS Interviews were conducted with (1) women who suffered a severe morbidity or nearmiss event, (2) family members of women who died or presented with a severe morbidity, and (3) community members or health workers involved in the care of the woman. MEASUREMENTS (1) Maternal mortality, (2) near-miss events, and (3) delays related to problem identification, transportation challenges and delays after reaching the referral site. FINDINGS 120 near-miss events and 28 maternal mortalities were analysed. 16% of all deliveries at the referral hospital were classified as near-miss events. Near-miss events were six times more common than deaths. The majority of women experiencing a near-miss event (85%) were in critical condition upon arrival at the hospital suggesting important delays were encountered in reaching the facility. KEY CONCLUSIONS Maternal mortality and near-miss audits allow exploration of medical and non-medical factors leading up to a severe complication or maternal death. Delays in reaching a referral hospital can have a significant impact on maternal survival rates. IMPLICATIONS FOR PRACTICE Audits can stimulate a change in clinical practice and help identify areas for county health departments to focus their scant resources. Audits can be used as a quality improvement tool in facilities. Results can be used to identify communities with high rates of delay to target educational programmes.
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Affiliation(s)
- Jody R Lori
- University of Michigan, School of Nursing, 400N. Ingalls Bldg., Room 4320B, Ann Arbor, MI 48109-5482, USA.
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Camargo RS, Pacagnella RC, Cecatti JG, Parpinelli MA, Souza JP, Sousa MH. Subsequent reproductive outcome in women who have experienced a potentially life-threatening condition or a maternal near-miss during pregnancy. Clinics (Sao Paulo) 2011; 66:1367-72. [PMID: 21915485 PMCID: PMC3161213 DOI: 10.1590/s1807-59322011000800010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 04/18/2011] [Accepted: 05/02/2011] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate the long-term reproductive consequences that affect women who have experienced potentially life-threatening or life-threatening (near-miss) maternal complications. INTRODUCTION Although advances have been made in reducing maternal death, few studies have investigated the long-term repercussions of significant events such as severe maternal morbidity and maternal near-misses. These repercussions may be long-lasting and negatively affect quality of life. METHODS A total of 382 women who had experienced a potentially life-threatening pregnancy-related condition within the last five years were analyzed in this retrospective cohort study. A control group of 188 women who gave birth without complications was also included. Trained interviewers contacted the subjects by telephone and completed a pre-coded, structured questionnaire on reproductive health. Data were analyzed using odds ratios adjusted for age. The main outcome measures were occurrence and outcome of subsequent pregnancies. RESULTS The estimated risk of becoming infertile as a result of tubal ligation or hysterectomy was 3.5 times higher in women who experienced a maternal near-miss or severe maternal morbidity during the index pregnancy as compared to controls. Likewise, the risk of complications in subsequent pregnancies was five times greater in women who had experienced severe maternal morbidity. However, no differences were found in the occurrence or number of subsequent pregnancies or perinatal outcome. CONCLUSION The occurrence of a life-threatening or potentially life-threatening maternal condition reduces future reproductive potential and increases the risk of complications in subsequent pregnancies.
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Affiliation(s)
- Rodrigo S Camargo
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
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Allen VM, Campbell M, Carson G, Fraser W, Liston RM, Walker M, Barrett J. Maternal Mortality and Severe Maternal Morbidity Surveillance in Canada. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2010; 32:1140-1146. [DOI: 10.1016/s1701-2163(16)34737-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Paech M, Sinha A. Obstetric audit and its implications for obstetric anaesthesia. Best Pract Res Clin Obstet Gynaecol 2010; 24:413-25. [DOI: 10.1016/j.bpobgyn.2009.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Accepted: 12/01/2009] [Indexed: 10/20/2022]
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van Dillen J, Mesman JAJM, Zwart JJ, Bloemenkamp KWM, van Roosmalen J. Introducing maternal morbidity audit in the Netherlands. BJOG 2010; 117:416-21. [PMID: 20105161 DOI: 10.1111/j.1471-0528.2009.02480.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe the panel audit process and to identify substandard care in selected women from a nationwide prospective cohort study into severe acute maternal morbidity (SAMM) in the Netherlands. DESIGN Prospective audit of selected women with SAMM. SETTING Eight audit meetings held throughout the Netherlands. POPULATION All pregnant women in the Netherlands. METHODS Before each meeting, SAMM details of selected women were sent to all panel members for individual assessment by completing an audit form. During a subsequent plenary meeting, findings were discussed and substandard care factors as judged by the majority of assessors were scored. MAIN OUTCOME MEASURES Incidence of substandard care and recommendations for improving the quality of care. RESULTS Substandard care was identified in 53 of 67 women (79%). Specific recommendations were formulated concerning the procedure of audit and concerning local as well as national management guidelines. CONCLUSION Our findings reflect SAMM in the Netherlands and substandard care is present in four out of five women. Ongoing audit of women with SAMM is promoted both at local and national level.
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Affiliation(s)
- J van Dillen
- Department of Obstetrics, Leiden University Medical Centre, Albinusdreef 2, Leiden, The Netherlands.
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van Roosmalen J, Zwart J. Severe acute maternal morbidity in high-income countries. Best Pract Res Clin Obstet Gynaecol 2009; 23:297-304. [PMID: 19213604 DOI: 10.1016/j.bpobgyn.2009.01.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2008] [Accepted: 01/14/2009] [Indexed: 10/21/2022]
Abstract
Maternal mortality in high income countries has become low in recent years and therefore analysis of severe acute maternal morbidity has been added to confidential enquiries into the causes of maternal deaths. The major drawback at the moment is the lack of universal definitions of severe acute maternal morbidity. The prevalence of severe acute maternal morbidity in high income countries is between 3.8 and 12 per 1,000 births. Case fatality rates may reflect the quality of maternal health care. Audit is the instrument to analyse whether substandard care factors are present. Guidelines and protocols to provide obstetric critical care may be improved from audit findings and skills and drills training put in place.
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Affiliation(s)
- Jos van Roosmalen
- Department of Obstetrics, Leiden University Medical Centre, The Netherlands.
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Zwart JJ, Richters JM, Ory F, de Vries JIP, Bloemenkamp KWM, van Roosmalen J. Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: a nationwide population-based study of 371,000 pregnancies. BJOG 2008; 115:842-50. [PMID: 18485162 DOI: 10.1111/j.1471-0528.2008.01713.x] [Citation(s) in RCA: 279] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To assess incidence, case fatality rate, risk factors and substandard care in severe maternal morbidity in the Netherlands. DESIGN Prospective population-based cohort study. SETTING All 98 maternity units in the Netherlands. POPULATION All pregnant women in the Netherlands. METHODS Cases of severe maternal morbidity were collected during a 2-year period. All pregnant women in the Netherlands in the same period acted as reference cohort (n = 371,021). As immigrant women are disproportionately represented in Dutch maternal mortality statistics, special attention was paid to the ethnic background. In a subset of 2.5% of women, substandard care was assessed through clinical audit. MAIN OUTCOME MEASURES Incidence, case fatality rates, possible risk factors and substandard care. RESULTS Severe maternal morbidity was reported in 2552 women, giving an overall incidence of 7.1 per 1000 deliveries. Intensive care unit admission was reported in 847 women (incidence 2.4 per 1000), uterine rupture in 218 women (incidence 6.1/10,000), eclampsia in 222 women (incidence 6.2/10,000) and major obstetric haemorrhage in 1606 women (incidence 4.5 per 1000). Non-Western immigrant women had a 1.3-fold increased risk of severe maternal morbidity (95% CI 1.2-1.5) when compared with Western women. Overall case fatality rate was 1 in 53. Substandard care was found in 39 of a subset of 63 women (62%) through clinical audit. CONCLUSIONS Severe maternal morbidity complicates at least 0.71% of all pregnancies in the Netherlands, immigrant women experiencing an increased risk. Since substandard care was found in the majority of assessed cases, reduction of severe maternal morbidity seems a mandatory challenge.
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Affiliation(s)
- J J Zwart
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands.
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Cecatti JG, Souza JP, Parpinelli MA, de Sousa MH, Amaral E. Research on Severe Maternal Morbidities and Near-Misses in Brazil: What We Have Learned. REPRODUCTIVE HEALTH MATTERS 2007; 15:125-33. [DOI: 10.1016/s0968-8080(07)30333-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Goffman D, Madden RC, Harrison EA, Merkatz IR, Chazotte C. Predictors of maternal mortality and near-miss maternal morbidity. J Perinatol 2007; 27:597-601. [PMID: 17703181 DOI: 10.1038/sj.jp.7211810] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To identify risk factors for life-threatening maternal outcomes. STUDY DESIGN Hospital charts were reviewed for cases of maternal mortality or near-miss and for controls overmatched 1:3. Significant risk factors were identified through simple and best subsets multiple logistic regression. RESULT Eight cases of mortality and 69 near-miss cases were found. Significant risk factors with their odds ratios and 95% confidence intervals are: age 35 to 39 years (2.3, 1.2 to 4.4) and >39 years (5.1, 1.8 to 14.4); African-American race (7.4, 2.5 to 22.0) and Hispanic ethnicity (4.2, 1.3 to 13.2); chronic medical condition (2.7, 1.5 to 4.8); obesity (3.0, 1.7 to 5.3); prior cesarean (5.2, 2.8 to 9.8) and gravidity (1.2, 1.1 to 1.5 per pregnancy). In multivariable logistic regression, race remained significant while controlling for other significant factors and markers of socioeconomic status. CONCLUSION Some risk factors can be modified through medical care, education or social support systems. Racial disparity in outcome is confirmed and is unexplained by traditional risk factors.
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Affiliation(s)
- D Goffman
- Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
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