Current status of pregnancy-related maternal mortality in Japan: a report from the Maternal Death Exploratory Committee in Japan

Educational results of the Japan Maternal Emergency Life-Saving (J-MELS) simulation training organized by Japan Council for the Implementation of the Maternal Emergency Life-Saving System (J-CIMELS): a 12-month longitudinal follow-up study in Japan

AIMS

This study aimed to evaluate the long-term results of Japan Maternal Emergency Life-Saving (J-MELS) simulation training on obstetric healthcare providers, over a 12-month follow-up period.

METHODS

A total of 273 trainees from 17 J-MELS Basic courses conducted between August 2021 and October 2023 were included. The trainees' responses to the pre- and post-tests, questionnaires, and self-reports on the usefulness of the J-MELS scenarios in actual clinical settings at 1, 6, and 12 months after the training were analyzed. Multivariate logistic regression analysis was also conducted to identify the factors influencing knowledge retention.

RESULTS

We found an overall improvement in clinical knowledge acquisition after J-MELS training and a significant retention of this improvement at least until 12 months later. However, these scores gradually declined over. Trainees reported increased usefulness of J-MELS scenarios in actual clinical practice at 1, 6, and 12 months after training, particularly in managing obstetric emergencies such as atonic postpartum hemorrhage. Knowledge retention was influenced by several specific factors, such as years of clinical experience, affiliated institutions, qualifications, and especially pre-test scores.

CONCLUSION

Our longitudinal follow-up study demonstrated, for the first time, the long-term results of J-MELS simulation training using post-tests and self-report data. Our findings provide valuable insight into the impact of J-MELS simulation training on maternal emergency care. By elucidating the factors influencing knowledge retention and practical utility, the findings offer actionable recommendations for optimizing training strategies and improving maternal outcomes in actual clinical practice.

Infection route associated with invasive group A streptococcal toxic shock syndrome in maternal deaths: Nationwide analysis of maternal mortalities in Japan

OBJECTIVES

To clarify the infection route in maternal death due to invasive group A streptococcal (GAS) infection and toxic shock syndrome (TSS).

METHODS

A retrospective study was conducted on maternal deaths due to GAS-TSS in Japan between January 2010 and March 2024. The final causal diagnosis of maternal death and the infection routes of GAS were analysed using medical records, laboratory data and autopsy findings.

RESULTS

Among the 616 maternal deaths during the study period, 48 (8%) involved infectious diseases. The most common infection was invasive GAS (56%, n = 27), 21 (78%) and six cases occurred during the antepartum and puerperium periods, respectively. In the GAS-TSS group, 71% (15/21) infections were originated the upper respiratory tract. However, in the puerperium cases, 67% (4/6) were infected from the genital tract. In addition, no maternal deaths due to GAS-TSS were reported during the COVID-19 pandemic period in Japan from 2020 to 2023.

CONCLUSION

Most antepartum GAS infections were from the upper respiratory tract. They may be reduced by preventive measures, including frequent disinfection, wearing masks and isolation from persons at high risk of carrying GAS, such as symptomatic children. On the other hand, GAS-TSS during puerperium infection via the genital tract.

Resuscitative endovascular balloon occlusion of the aorta: A novel approach for treating amniotic fluid embolism with disseminated intravascular coagulopathy-A report of two cases

We present two critical cases of life-threatening postpartum hemorrhage (PPH) due to amniotic fluid embolism (AFE) complicated by disseminated intravascular coagulopathy (DIC). These cases are the first to show the effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) for patient survival. In Case 1, the patient, experiencing critical conditions with severe PPH and DIC despite conventional treatments, including rapid blood transfusion and fibrinogen concentrate, was air-transferred to our hospital, where REBOA was promptly employed before hysterectomy was completed. Case 2 involved an ambulance-transferred patient with massive PPH and DIC despite conventional treatments. Prehospital REBOA was performed to prevent cardiac arrest during transfer, and hysterectomy was performed in the hospital. Given the rapid deterioration associated with AFE, REBOA can serve as a bridge until complete hemostasis to maintain vital signs and control bleeding in patients unresponsive to standard therapies before hemostatic interventions or during transfer.

Changes in use and outcomes after fibrinogen concentrate insurance coverage for critical obstetrical hemorrhage: a nationwide questionnaire survey in Japan

Fibrinogen concentrate (FC) for acquired hypofibrinogenemia associated with critical obstetrical hemorrhage (COH) was covered by public medical insurance in September 2021 in Japan. We aimed to investigate changes in the policy of FC use and its effect on COH after insurance coverage. A primary survey covering September 2020 to August 2021 and a secondary survey covering September 2021 to August 2022 were conducted at 428 higher-level medical facilities. We investigated the policy of FC use in transfusion strategy and the maternal outcomes in COH. Among the hospitals that responded to both surveys, the number of facilities that use FC increased from 51.5 (101/196) to 78.6% (154/196) (P < 0.0001). The number of COH cases treated using FC increased from 14.3 to 24.3% (P < 0.0001) and that transfused with ≥ 10 units of red blood cells (RBCs) decreased from 36.8 to 29.8% (P = 0.001). The incidence of pulmonary edema reduced by 3.7-2.0% (P = 0.021), and transfusion-induced allergy by 1.9-0.7% (P = 0.008). No changes were observed in the incidence of thromboembolism, arterial embolization, or hysterectomy. The increased use of FC after insurance coverage led to changes in the transfusion strategy, which may be associated with decreases in transfusions of RBCs, pulmonary edema, and transfusion-induced allergies.

Current status of the position on labor progress prediction for contemporary pregnant women using Friedman curves: An updated review

AIM

Prediction of labor progression is important for maternal and fetal health, as improved accuracy can lead to more timely intervention and improved outcomes. This review aims to outline the importance of predicting the progression of spontaneous parturition, detail the various methods employed to enhance this prediction and provide recommendations for future research.

METHODS

We searched articles relating to labor progression and systematic review articles on Artificial Inteligence (AI) in childbirth management using PubMed. To supplement, Google Scholar was used to find recent guidelines and related documents.

RESULTS

Traditional methods like vaginal examinations, criticized for subjectivity and inaccuracy, are gradually being replaced by ultrasound, considered a more objective and accurate approach. Further advancements have been observed with machine learning and artificial intelligence techniques, which promise to surpass the accuracies of conventional methods. The Friedman curve, developed in 1954, is the standard for assessing labor progress, but its application to Asian women, in particular, remains controversial, and various studies have reported that the actual rate of labor was slower than that indicated by the Friedman curve.

CONCLUSION

There is a need to innovate methodologies for predicting delivery tailored to modern pregnant women, especially when they have different genetic and cultural backgrounds than their Western counterparts, such as Asians. Future research should develop predictive models of labor progression that aim to enhance medical intervention and improve the safety and well-being of both mother and child.

Clinical Prediction of Retained Products of Conception: Combining Obstetric History and Ultrasound for Improved Accuracy in Severe Postpartum Hemorrhage

Background The current challenge is how to improve the management of postpartum hemorrhage (PPH) to reduce the maternal mortality rate further. This study aimed to investigate whether a combined specific obstetric history and ultrasonographic findings can improve the predictive accuracy of retained products of conception (RPOC) with severe PPH. Methods This retrospective study included 56 patients who were diagnosed with RPOC. We extracted the following clinical data: obstetric history of second-trimester miscarriage, the time at which there was clinical suspicion of RPOC after the previous pregnancy (TIME), grayscale ultrasonographic finding (RPOC long-axis length [SIZE]), and color Doppler ultrasonographic finding based on the Gutenberg classification (RPOC hypervascularity). In this study, we defined cases requiring blood transfusion therapy or transcatheter arterial embolization as severe PPH. The patients were divided into two groups according to the presence or absence of severe PPH. The predictors of severe PPH were evaluated using logistic regression models. Model A comprised a combination of second-trimester miscarriage and TIME, Model B comprised a combination of Model A and long-axis SIZE, and Model C comprised a combination of Model B and RPOC hypervascularity. Results The multivariable analysis showed that long-axis SIZE was the only significant predictor of severe PPH (odds ratio [OR], 10.38; 95% confidence interval [CI], 2.06-63.86) independent of second-trimester miscarriage, TIME, and RPOC hypervascularity. The c-statistic was higher in Model C (OR, 0.863; 95% CI, 0.731-0.936) than in Model A (OR, 0.723; 95% CI, 0.551-0.847) and Model B (OR, 0.834; 95% CI, 0.677-0.923). Conclusion Combining a specific obstetric history (second-trimester miscarriage and TIME) and ultrasonographic findings (long-axis SIZE and RPOC hypervascularity) improves the predictive accuracy of RPOC with severe PPH. This prediction model may be a useful clinical screening tool for RPOC with severe PPH.

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

OBJECTIVE

Cardiovascular disease (CVD) is the leading cause of maternal deaths in high-income countries. This study aimed to assess the characteristics of maternal deaths due to CVDs and the quality of care provided to patients, and to identify elements to improve maternal care in Japan.

METHODS

This descriptive study used the maternal death registration data of the Maternal Deaths Exploratory Committee of Japan between 2010 and 2019.

RESULTS

Of 445 eligible pregnancy-related maternal deaths, 44 (9.9%) were attributed to CVD. The most frequent cause was aortic dissection (18 patients, 40.9%), followed by peripartum cardiomyopathy (8 patients, 18.2%), and pulmonary hypertension (5 patients, 11.4%). In 31.8% of cases, cardiopulmonary arrest occurred within 30 min after initial symptoms. Frequent symptoms included pain (27.3%) and respiratory symptoms (27.3%), with 61.4% having initial symptoms during the prenatal period. 63.6% of the patients had known risk factors, with age ≥35 years (38.6％), hypertensive disorder (15.9%), and obesity (15.9%) being the most common. Quality of care was assessed as suboptimal in 16 (36.4%) patients. Cardiac risk assessment was insufficient in three patients with preexisting cardiac disease, while 13 patients had symptoms and risk factors warranting intensive monitoring and evaluation.

CONCLUSION

Aortic dissection was the leading cause of maternal death due to CVDs. Obstetrics care providers need to be familiar with cardiac risk factors and clinical warning signs that may lead to impending fatal cardiac events. Timely risk assessment, patient awareness, and a multidisciplinary team approach are key to improving maternal care in Japan.

Effectiveness of call system implementation for postpartum hemorrhage in a tertiary emergency medical center: a retrospective cohort study

BACKGROUND

Postpartum hemorrhage is the leading cause of maternal death and severe maternal morbidity worldwide. Previous studies have reported the importance of multidisciplinary treatment approaches for postpartum hemorrhage; however, only a few studies have shown a clear improvement in maternal outcomes. Therefore, this study aimed to investigate the efficacy of a call system for postpartum hemorrhage in a tertiary emergency facility for rapid multidisciplinary treatment and its effect on maternal outcomes.

METHODS

This single-center retrospective cohort study included patients transferred to our hospital due to postpartum hemorrhage between April 1, 2013, and March 31, 2019. The primary outcome was mortality, and the secondary outcomes were morbidity (duration of hospital stay, duration of intensive care unit stay, admission to the intensive care unit, respirator use, duration of ventilator support, acute kidney injury, transfusion-associated circulatory overload/transfusion-related acute lung injury, hysterectomy, composite adverse events, blood transfusion initiation time, blood transfusion volume, and treatment for postpartum hemorrhage). An in-hospital call system implementation commenced on April 1, 2016. The study outcomes were compared 3 years before and after implementing the call system.

RESULTS

The blood transfusion initiation time and duration of hospital stay were significantly shortened after implementing the call system for postpartum hemorrhage. No maternal deaths were observed after implementing the system.

CONCLUSIONS

Implementing call systems specialized for postpartum hemorrhage in tertiary emergency facilities may improve maternal outcomes.

Hypertensive disorders of pregnancy in moyamoya disease: A single institution experience

OBJECTIVE

The characteristics of pregnancy and delivery in patients with moyamoya disease (MMD) remain unclear. We retrospectively investigated perinatal outcomes in patients with MMD to evaluate the risks associated to this condition.

MATERIALS AND METHODS

Clinical data of women with MMD who delivered at the University of Tokyo Hospital between 2000 and 2021 were collected. Maternal characteristics including genetic data, obstetric complications, method of delivery and anesthesia, neonatal outcomes, neurological events during pregnancy, delivery, and postpartum course, were reviewed.

RESULTS

Thirteen pregnancies with MMD were identified. The median maternal age was 30 years. The initial clinical symptoms were identified as transient ischemic attack, infarction, and headache. Eight patients had a history of bypass surgery. The median gestational age at delivery was 37 weeks. DNA samples were collected from five patients, responsible for six pregnancies. Of these six cases, five had the RNF213 c.14429G > A (p.Arg4810Lys) heterozygous variant. Of the 13 pregnancies, seven had hypertensive disorder of pregnancy (HDP). Additionally, three of five pregnancy cases with RNF213 p.Arg4810Lys heterozygous variant presented with HDP. Nine patients underwent cesarean section, and four delivered vaginally with epidural anesthesia. One case of ischemic stroke was confirmed during the postpartum period. Regarding newborns, neither Apgar scores lower than 7 nor neonatal intensive care unit admissions were reported.

CONCLUSIONS

This study suggests that the frequency of HDP is higher in patients with MMD compared to those with normal pregnancies. Strict blood pressure control should be performed in patients with MMD during pregnancy and postpartum period.

Activities of the Japan Council for Implementation of the Maternal Emergency Life Support System reduced direct causes of maternal deaths in Japan

Here, we aimed to provide an overview of Japan Council for the Implementation of the Maternal Emergency Life-Saving System (J-CIMELS) and its simulation program, which has reduced maternal mortality due to direct causes in Japan. The Japan Association of Obstetricians and Gynecologists (JAOG), Japan Association of Obstetricians and Gynecologists, and Maternal Death Exploratory Committee (JMDEC) launched the Maternal Death Reporting Project in 2010. The project analyzed obstetricians' tendency to delay their initial response to sudden maternal deterioration. Obstetricians can predict small changes before deterioration by monitoring vital signs. In 2015, the J-CIMELS was established to provide practical education. J-CIMELS developed a simulation program (J-MELS; Japan Maternal Emergency Life Support) to ensure that the obstetricians acquire the latest knowledge of emergency physicians, anesthesiologists, and other general practitioners and apply it in clinical situations. In the last 7 years, the J-MELS basic course has been conducted 1000 times with a total attendance of 19 890 people. As a result, the incidence of obstetric hemorrhage progressively decreased from 29% in 2010 to 7% in 2020. We believe that the activities of J-CIMELS are improving obstetric care providers' medical practices in Japan.

A case of cardiac arrest due to postpartum hemorrhage treated with hysterectomy and extracorporeal membrane oxygenation

Although extracorporeal membrane oxygenation is relatively contraindicated in patients with severe disseminated intravascular coagulation (DIC), it can be safely introduced by providing adequate anti-DIC therapy.

Global issues in obstetric anaesthesia: perspectives from South Africa, Japan, China, Latin America and North America

South Africa is classified as a low- and middle-income country, with a complex mixture of resource-rich and resource-limited settings. In the major referral hospitals, the necessary skill level exists for the management of complex challenges. However, this contrasts with the frequently-inadequate skill levels of anaesthesia practitioners in resource-limited environments. In Japan, obstetricians administer anaesthesia for 40% of caesarean deliveries and 80% of labour analgesia. Centralisation of delivery facilities is now occurring and it is expected that obstetric anaesthesiologists will be available 24 h a day in centralised facilities in the future. In China, improvements in women's reproductive, maternal, neonatal, child, and adolescent health are critical government policies. Obstetric anaesthesia, especially labour analgesia, has received unprecedented attention. Chinese obstetric anaesthesiologists are passionate about clinical research, focusing on efficacy, safety, and topical issues. The Latin-American region has different landscapes, people, languages, and cultures, and is one of the world's regions with the most inequality. There are large gaps in research, knowledge, and health services, and the World Federation of Societies of Anaesthesiologists is committed to working with governmental and non-governmental organisations to improve patient care and access to safe anaesthesia. Anaesthesia workforce challenges, exacerbated by coronavirus disease 2019, beset North American healthcare. Pre-existing struggles by governments and decision-makers to improve health care access remain, partly due to unfamiliarity with the role of the anaesthesiologist. In addition to weaknesses in work environments and dated standards of work culture, the work-life balance demanded by new generations of anaesthesiologists must be acknowledged.

Maternal sudden death: A nationwide retrospective study

OBJECTIVE

To determine the prevalence of maternal sudden death (MSD) and to compare the characteristics of death between women with explained and unexplained sudden death.

DESIGN

A national retrospective study in France.

POPULATION

Maternal deaths related to an unexpected sudden cardiac arrest were extracted from the French National Confidential Enquiry into Maternal Deaths database for 2007-2012.

METHODS

Maternal, pregnancy, sudden death characteristics and maternal investigations were compared between women with explained and unexplained cause of death.

RESULTS

A total of 83 maternal sudden deaths and 4 949 890 live births occurred over the period studied, thus accounting for 16% of all maternal deaths (n = 510). Death was explained in 51 (61%) women and unexplained in 32 women (39%). Compared with women with unexplained death, women with explained death were more often found to have in-hospital cardiac arrest (47% versus 12%, P < 0.01), witnessed cardiac arrest (86% versus 62%, P = 0.03) and in-hospital death (82% versus 47%, P < 0.01). Postmortem investigations such as autopsy and/or CT scan (65% versus 31%, P < 0.01) were also more often carried out in women with explained death. The proportion of deaths for which the preventability factors could not be assessed was 58% among unexplained MSD and 7% among explained MSD.

CONCLUSION

Maternal sudden death is a rare event but accounts for a high proportion of all maternal deaths. This highlights the importance of providing training in diagnostic and management strategy for care providers. Systematic postmortem investigations are required to help understand causes and improve practices.

Trend in neuraxial morphine use and postoperative analgesia after cesarean delivery in Japan from 2005 to 2020

The increasing rate of cesarean deliveries warrants obstetric anesthesiologists to deliver high-quality post-cesarean delivery analgesia. The aim of this study was to evaluate the temporal trends in the use of neuraxial morphine for cesarean deliveries and to describe the current postoperative analgesia practices. A retrospective cohort study using nationwide health insurance claims databases was conducted from 2005 to 2020 in Japan. Pregnant women who had undergone cesarean deliveries were included. The annual rate of neuraxial morphine use was extracted and analyzed. Additionally, we explored the patient- and facility-level factors associated with neuraxial morphine use through a multilevel logistic regression analysis. The cohort included 65,208 cesarean delivery cases from 2275 institutions. The prevalence of neuraxial morphine use was 16.0% (95% confidence interval [CI], 15.8-16.3) in the overall cohort. Intrathecal morphine was used in 20.6% (95% CI, 20.2-21.0) of spinal anesthesia cases. The trend in neuraxial morphine use steadily increased from 2005 to 2020. The significant predictors of neuraxial morphine use included spinal anesthesia, recent surgery, large medical facilities, and academic hospitals. Variations in the utilization of postoperative analgesia were observed. Our study described the current trend of neuraxial morphine use and the variation in postoperative analgesia practice in Japan.

Obstetric venous thromboembolism: Evaluation of prophylactic approach based on risk scores, D-dimer levels, and ultrasonography findings in a tertiary hospital in Japan

AIM

Pulmonary embolism remains a leading cause of maternal mortality in developed countries despite developments in venous thromboembolism prophylaxis strategies. This study aimed to evaluate the effectiveness of our approach involving risk-scoring, D-dimer level assessment, and ultrasonography for obstetric venous thromboembolism.

METHODS

This retrospective cohort study included women who delivered at 22-41 weeks of gestation in The University of Tsukuba Hospital, Japan between January and December 2020. Venous thromboembolism risk (determined according to Japanese guidelines) and D-dimer levels were evaluated within 20 weeks of gestation, 30-34 weeks of gestation, and during the pre-delivery period (36 weeks of gestation or any time before preterm delivery). Compression and color Doppler ultrasonography for lower extremity deep vein thrombosis were performed if D-dimer levels were ≥3.2 μg/mL (for those undergoing cesarean delivery, 1.0 μg/mL).

RESULTS

Of 1026 women, 6 women had deep vein thrombosis during pregnancy and 1 during the puerperium period. Pulmonary embolism was not observed. The D-dimer screening result was positive for 8 women (2%) within 20 weeks of gestation (deep vein thrombosis was confirmed in 3 of them), 87 women (10%) (no deep vein thrombosis) at 30-34 weeks of gestation, and 367 women (36%) during the pre-delivery period (asymptomatic deep vein thrombosis in one). Based on the Japanese guidelines, 1%, 11%, 33%, and 55% of women had high, intermediate, low, and no postpartum risk factors, respectively.

CONCLUSIONS

Our approach appears useful for antenatal venous thromboembolism screening in the first trimester. For postpartum prophylaxis, more cost-effective strategies are needed.

Impact of efforts to prevent maternal deaths due to obstetric hemorrhage on trends in epidemiology and management of severe postpartum hemorrhage in Japan: a nationwide retrospective study

Background

The Japan Society of Obstetrics and Gynecology and the Japan Association of Obstetricians and Gynecologists have issued the guidelines and recommendations on postpartum hemorrhage since 2010 and have been conducted widespread educational activities from 2012. The aim of this study was to investigate the impact of these efforts by the Societies to prevent maternal deaths due to obstetric hemorrhage on trends in epidemiology and management of severe postpartum hemorrhage in Japan.

Methods

A national retrospective cohort study was conducted using the national database of health insurance claims for the period 2012 and 2018. The subjects were all insured women who received a blood transfusion for postpartum hemorrhage. The primary endpoints of this study were hysterectomy and maternal mortality. The etiology of hemorrhage, treatment facility, type of procedure, and blood transfusion volume were tabulated.

Results

Women with postpartum hemorrhage that underwent transfusion increased from 3.5 to 5.5 per 1000 deliveries between 2012 and 2018. The most common cause of postpartum hemorrhage was atonic hemorrhage. After insurance coverage in 2013, the intrauterine balloon tamponade use increased to 20.3% of postpartum hemorrhages treated with transfusion in 2018, while the proportion of hysterectomy was decreased from 7.6% (2013–2015) to 6.4% (2016–2018) (p < 0.0001). The proportion of postpartum hemorrhage in maternal deaths decreased from 21.1% (2013–2015) to 14.1% (2016–2018) per all maternal deaths cases (p = 0.14). Cases with postpartum hemorrhage managed in large referral hospitals was increased (65.9% in 2012 to 70.4% in 2018) during the study period (p < 0.0001).

Conclusions

The efforts by the Societies to prevent maternal mortality due to obstetric hemorrhage resulted in a significant decrease in the frequency of hysterectomies and a downward trend in maternal mortality due to obstetric hemorrhage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04824-7.

Resuscitative endovascular balloon occlusion of the aorta for life-threatening postpartum hemorrhage: A nationwide observational study in Japan

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used for postpartum hemorrhage (PPH) which is one of the leading causes of maternal mortality worldwide; however, its utility in the obstetrics setting remains unclear. Thus, this study aimed to describe the characteristics, demographics and mortality of patients with PPH who underwent REBOA.

METHODS

We used the Japanese Diagnosis Procedure Combination inpatient database to identify patients with PPH who underwent REBOA from April 2012 to March 2020. We examined the patients' characteristics, interventions administered and in-hospital mortality.

RESULTS

We identified 143 patients with PPH who underwent REBOA. The most common cause of PPH was atonic postpartum hemorrhage (52.4%), followed by disseminated intravascular coagulation (29.4%) and amniotic fluid embolism documented (11.2%). Among patients who delivered at hospitals in which REBOA was performed (n = 55), 38.2% of patients experienced preterm births and 70.9% delivered via cesarean section. The proportion of patients who underwent transcatheter arterial embolization and hysterectomy was 53.8% and 16.1%, respectively. In-hospital mortality was 7.0%.

CONCLUSION

The results of the present study could be helpful in clinical decision-making and providing patients and families with additional treatment options for PPH.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Nonovert disseminated intravascular coagulation (DIC) in pregnancy: a new scoring system for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion

BACKGROUND

Nonovert disseminated intravascular coagulation (DIC) is a subclinical hemostatic dysfunction that has not yet reached the decompensation stage. The detection of pregnant patients at this stage may assist in the identification of those who will develop severe obstetrical hemorrhage, as it is one of the leading causes for preventable maternal mortality. Currently, nonovert DIC is diagnosed by a scoring system based on nonpregnant patients, originally generated by the International Society on Thrombosis and Hemostasis (ISTH), which does not address the physiologic changes of the hemostatic system during pregnancy.

OBJECTIVES

(1) To develop a pregnancy-specific nonovert DIC score, (2) to determine the diagnostic performance of this score in detecting women at risk for obstetrical hemorrhage requiring blood product transfusion, and (3) to compare it to the existing ISTH nonovert DIC score.

STUDY DESIGN

This retrospective study has longitudinal and cross-sectional components and includes three steps: (1) characterization of the longitudinal changes in the components of modified ISTH nonovert DIC scores, including these parameters - fibrinogen, antithrombin III, protein C, prothrombin time (PT), platelets, thrombin-antithrombin (TAT) complex, and D-dimer - during gestation in a group of normal pregnancies (n = 50); (2) development of a pregnancy-specific nonovert DIC score in a cross-sectional design of high-risk (n = 152) and control (n = 50) pregnancies, based on the predictive performance of each analyte for the detection of women at risk for obstetrical hemorrhage requiring blood product transfusion and a logistic regression model; and (3) comparison between the diagnostic performance of the pregnancy-specific nonovert DIC score and the modified ISTH nonovert DIC score to detect, upon admission, women who are at increased risk for subsequent development of obstetrical hemorrhage requiring blood product transfusion.

RESULTS

(1) The study cohort included 202 patients, of which 21 (10%) had obstetrical hemorrhage that required blood product transfusion and were considered to have nonovert DIC; (2) using the nonpregnant ISTH nonovert DIC score, 92% of the patients had a D-dimer concentration above the 0.5 mg/L threshold, and only 2% were identified to have a low fibrinogen concentration (<100 mg/dL); thus, this scoring system was unable to identify any of the patients with nonovert DIC based on the suggested cutoff of a score of ≥5; (3) the parameters included in the pregnancy-specific nonovert DIC score were selected based on their contribution to the performance of the model for the prediction of women at risk for obstetrical hemorrhage requiring blood product transfusion; as a result, we excluded the PT difference parameter from the score and the TAT complex concentration was added; and (4) a pregnancy-specific nonovert DIC score of ≥3 had a sensitivity of 71.4% and a specificity of 77.9% to identify patients at risk for obstetrical hemorrhage requiring blood product transfusion.

CONCLUSION

We propose (1) a pregnancy-specific nonovert DIC score adjusted for the physiologic changes in the hemostatic system during gestation; and (2) that the pregnancy-specific nonovert DIC score can be a useful tool for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion.

Intravenous infusion route in maternal resuscitation: a scoping review

BACKGROUND

The concept that upper extremities can be used as an infusion route during cardiopulmonary resuscitation in pregnant women is a reasonable recommendation considering the characteristic circulation of pregnant women; however, this method is not based on scientific evidence.

OBJECTIVE OF THE REVIEW

We conducted a scoping review to determine whether the infusion route should be established above the diaphragm during cardiopulmonary resuscitation in a pregnant woman.

DISCUSSION

We included randomized controlled trials (RCTs) and non-RCTs on the infusion of fluids in pregnant women after 20 weeks of gestation requiring establishment of an infusion route due to cardiac arrest, massive bleeding, intra-abdominal bleeding, cesarean section, severe infection, or thrombosis. In total, 3150 articles from electronic database were extracted, respectively. After title and abstract review, 265 articles were extracted, and 116 articles were extracted by full-text screening, which were included in the final analysis. The 116 articles included 78 studies on infusion for pregnant women. The location of the intravenous infusion route could be confirmed in only 17 studies, all of which used the upper extremity to secure the venous route.

CONCLUSION

Pregnant women undergo significant physiological changes that differ from those of normal adults, because of pressure and drainage of the inferior vena cava and pelvic veins by the enlarged uterus. Therefore, despite a lack of evidence, it seems logical to secure the infusion route above the diaphragm when resuscitating a pregnant woman.

Successful interhospital transfer for extracorporeal cardiopulmonary resuscitation of a patient who had a cardiac arrest after cesarean section

Background

Studies describing the effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for peripartum cardiopulmonary arrest are lacking.

Case Presentation

A 39‐year‐old woman underwent elective cesarean section. Right after surgery, she fell into a cardiac arrest and was promptly transferred to our institute by ambulance. On arrival, we immediately initiated ECPR, within 63 min of the cardiac arrest. Return of spontaneous circulation was achieved 80 min after induction of extracorporeal membrane oxygenation. As the hemodynamics of the patient stabilized, extracorporeal membrane oxygenation was discontinued on day 3 of hospitalization. The patient’s cerebral performance category score was 3 at discharge, which improved to 2 after 3 months.

Conclusion

This case suggests that prompt interhospital transfer and ECPR might be effective for peripartum cardiac arrest due to nonhemorrhagic events.

[A case of antepartum reversible cerebral vasoconstriction syndrome]

A 35-year-old pregnant woman with mild migraine experienced thunderclap headache at 37 weeks of gestation. Her cerebral MRA showed arterial segmental narrowing of right middle cerebral artery and bilateral posterior cerebral artery. When admitted, she had no sign of eclampsia/preeclampsia. After 4 days, she had premature rupture of the membrane and gave birth by caesarean section. Caesarean section immediately resolved the headache. The postpartum course of the patient and her baby was uneventfull. One month after her onset, her cerebral MRA showed improvement in arterial segmental narrowing of cerebral artery. We diagnosed reversible cerebral vasoconstriction syndrome (RCVS) assoiated with pregnancy. Pregnancy-related RCVS develops primarily during the puerperal period, but our case was a rare case that developed just before delivery and was successful with aggressive intervention. When antepartum RCVS develops, early cesarean section with epidural anesthesia in parallel with active treatment for headache may lead to good outcomes for both mother and child.

Trends, causes and solutions of maternal mortality in Jinan, China: the epidemiology of the MMR in 1991-2020

BACKGROUND

China was one of the few countries to achieve the Millennium Development Goals 5. China had taken many effective measures to reduce maternal mortality ratio (MMR) and has achieved encouraging progress. These measures were worth sharing for other countries to reduce the MMR, but the introduction of these measures from the national perspective was too grand, and the measures implemented in a city and the results achieved were more valuable. However, there were few studies on the prevalence and trends of prolonged maternal mortality in a city. In this study, we mainly introduced the prevalence of the MMR in Jinan,China from 1991 to 2020, analyzed the causes of trends and put forward some solutions to the difficulty existing in the process of reducing the MMR,hoping to serve as a model for some developing cities to reduce MMR.

METHODS

We collected maternal mortality data from paper records, electronic files and network platforms. The time trend of MMR was tested by Cochran-Armitage Test (CAT). We divided the study period into three stages with 10 years as a stage and the Chi-square test or Fisher's exact test was used to test the difference in MMR of different periods.

RESULTS

From 1991 to 2020, We counted 1,804,162 live births and 323 maternal deaths, and the MMR was 17.93 per 100,000 live births. The MMR declined from 44.06 per 100,000 live births in 1991 to 5.94 per 100,000 live births in 2020, with a total decline of 86.52% and an annual decline of 2.89%. The MMR declined by 88.54% in rural areas, with an average annual decline 2.95%, faster than that in urban areas (82.06, 2.73%). From 1991 to 2020, the top five causes of maternal deaths were obstetric haemorrhage (4.55 per 100,000 live births), amniotic fluid embolism (3.27 per 100,000 live births), pregnancy-induced hypertension (2.61 per 100,000 live births), heart disease (2.33 per 100,000 live births) and other medical complications (2.05 per 100,000 live births). Postpartum hemorrhage, amniotic fluid embolism, pregnancy-induced hypertension showed a downward trend (P < 0.05) and other medical complications showed an upward trend (P < 0.05).

CONCLUSIONS

Subsidy for hospitalized delivery of rural women, free prenatal check-ups for pregnant women and rapid referral system between hospitals have contributed to reducing MMR in Jinan. However, it was still necessary to strengthen the treatment of obstetric hemorrhage by ensuring blood supply, reduce the MMR due to medical complications by improving the skills of obstetricians to deal with medical diseases, and reduce the MMR by strengthening the allocation of emergency equipment in county hospitals and the skills training of doctors.

Heated tobacco product use and hypertensive disorders of pregnancy and low birth weight: analysis of a cross-sectional, web-based survey in Japan

OBJECTIVES

Knowledge on the impact of heated tobacco product (HTP) use in pregnant women with associated maternal and neonatal risks for hypertensive disorders of pregnancy (HDP) and low birth weight (LBW) is limited. We aimed to assess the status of HTP use among pregnant women in Japan and explore the association of HTP use with HDP and LBW.

DESIGN

Cross-sectional study.

SETTING

Data from the Japan 'COVID-19 and Society' Internet Survey study, a web-based nationwide survey.

PARTICIPANTS

We investigated 558 postdelivery and 365 currently pregnant women in October 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

Information on HDP and LBW was collected from the postdelivery women's Maternal and Child Health Handbooks (maternal and newborn records). We estimated the age-adjusted ORs and 95% CIs of ever HTP smokers for HDP and LBW and compared them with those of never HTP smokers in a logistic regression analysis.

RESULTS

The prevalence of ever and current HTP use were 11.7% and 2.7% in postdelivery women and 12.6% and 1.1% in currently pregnant women, respectively. Among currently pregnant women who were former combustible cigarette smokers, 4.4% (4/91) were current HTP smokers. Among postdelivery women, ever HTP smokers had a higher HDP incidence (13.8% vs 6.5%, p=0.03; age-adjusted OR=2.48, 95% CI 1.11 to 5.53) and higher LBW incidence (18.5% vs 8.9%, p=0.02; age-adjusted OR=2.36, 95% CI 1.16 to 4.87).

CONCLUSIONS

In Japan, the incidence of ever HTP use exceeded 10% among pregnant women, and HTP smoking may be associated with maternal and neonatal risks.

Prevalence and risk factors of labor-onset hypertension: A multicenter study in Japan

OBJECTIVES

To investigate the prevalence and risk factors of labor-onset hypertension (LOH), defined as hypertension first detected during labor among women without hypertension prior to admission for labor.

STUDY DESIGN

In this multicenter retrospective study, clinical data of women who delivered vaginally at term between 2012 and 2018 were collected from 12 primary maternity care units. Blood pressure was measured at five time points from admission to 2 h postpartum in a total of 30,129 normotensive women at the last prenatal check-up. LOH was defined as systolic blood pressure (SBP) of ≥ 140 mmHg or diastolic blood pressure (DBP) of ≥ 90 mmHg during the first to fourth stages of labor.

MAIN OUTCOME MEASURES

Multivariate regression analyses were conducted to evaluate the risk factors of LOH and severe LOH (SBP of ≥ 160 mmHg or DBP of ≥ 110 mmHg).

RESULTS

Among the 30,129 women, 8,565 (28.4%) presented with LOH and 734 (2.4%) with severe LOH. The prevalence of LOH was the highest at the second stage of labor (21.7%) and decreased rapidly after delivery. The independent risk factors of LOH were maternal age of ≥ 35 years, pre-pregnancy body mass index of ≥ 25 kg/m², and pregnancy weight gain of ≥ 15 kg.

CONCLUSION

LOH is common, with approximately one in four women experiencing LOH during labor and early postpartum. Meanwhile, severe LOH occurred in 2.4% of the pregnancies. Closer blood pressure monitoring during labor may enable obstetric caregivers to recognize LOH in a timely manner and reduce maternal adverse outcomes, such as eclampsia and stroke.

"Step-by-Step" Minimally Invasive Hemostatic Technique Using Intrauterine Double-Balloon Tamponade Combined with Uterine Isthmus Vertical Compression Suture for the Control of Placenta Accreta and Severe Atonic Hemorrhage during a Cesarean Section

A sudden onset of postpartum hemorrhage (PPH) during a cesarean delivery requires urgent hemostasis procedures, such as the B-Lynch, Hayman, or double-vertical compression sutures, when bimanual compression, uterotonic agent administration, and intrauterine balloon tamponade had failed to achieve sufficient hemostasis. However, after invasive hemostatic procedures, postoperative complications, including subsequent synechiae and infection followed by ischemia, have been reported to occur even in successful cases. To avoid these complications, we devised and performed a minimally invasive combined technique based on a “step-by-step” minimally invasive hemostatic protocol for a case of placenta accreta and severe atonic hemorrhage during a cesarean delivery. A nullipara woman with a history of systemic lupus erythematosus and treatment with prednisolone and tacrolimus underwent a cesarean section because of a nonreassuring fetal status. Severe atonic hemorrhage and placenta accreta were observed which did not respond to bimanual compression and uterotonics. Because severe uterine atony and continuous bleeding from the placental attachment area were observed even with intrauterine balloon tamponade, vertical compression sutures were placed in the uterine isthmus. However, severe uterine atony and atonic bleeding from the uterine corpus persisted; thus, a second balloon was inserted into the uterine corpus. Hemostasis was accomplished with a combination of isthmus vertical compression sutures and double balloons which is a less-invasive approach than existing compression techniques. No complications related to these procedures were observed. This step-by-step minimally invasive hemostatic technique has the potential to control PPH with less complications, especially in immunocompromised patients.

Capacity of Japanese institutions to manage obstetrical disseminated intravascular coagulation in 2018: A national surveillance questionnaire and retrospective cohort study

AIM

To investigate the management of obstetrical disseminated intravascular coagulation (DIC) in Japan.

METHODS

We sent a surveillance questionnaire to 2299 institutions to collect details about the deliveries they performed in 2018. We investigated differences in the management of obstetrical DIC among three types of institutions: perinatal medical centers (PMCs), general hospitals with obstetrical facilities (GHs), and maternal clinics with beds (MCs).

RESULTS

We received responses from 703 institutions (30.6% of the total mailed) with results of 306 799 women who gave birth in 2018. In Japan, the potential to treat postpartum hemorrhage and obstetrical DIC was high in the PMC group, moderate in the GH group, and low in the MC group. The incidence of obstetrical DIC in the PMC group (0.44%) was significantly higher than that in the GH (0.21%) and MC (0.06%) groups. The mortality of women with obstetrical DIC in PMCs (1.3%) was similar to that in GHs (0.6%) and MCs (0.0%). The percentages of PMCs that always or sometimes transfused fresh frozen plasma or fibrinogen concentrates (100% and 42.2%, respectively) were significantly higher than those in the GH (88.2% and 29.5%, respectively) and MC groups (29.4% and 5.3%, respectively). Furthermore, institutions whose internal protocols mandated that replacement therapy be always administered in women with obstetrical DIC scores of ≥8 had similar protocols to those for women with fibrinogen levels of ≤1.5 g/L.

CONCLUSIONS

The capacity to provide therapy for postpartum hemorrhage and obstetrical DIC varied widely among the three groups of institutions.

The utility of shock index and heart rate in the management of postpartum blood loss in pregnant women complicated with hypertensive disorders in pregnancy

BACKGROUND

Although the shock index (SI) (heart rate/systolic blood pressure) and heart rate (HR) are a helpful indicator in the management of postpartum blood loss, there are few reports of SI in pregnant women complicated with hypertensive disorders in pregnancy (HDP). The purpose of this study was to examine whether SI and HR would be a clinically helpful indicator, and to detect the cutoff value for judging abnormal obstetric bleeding.

METHODS

This was a retrospective case-control study in 107 patients with HDP in a singleton tertiary perinatal medical facility. The values of postpartum highest SI (peak SI) and highest HR (peak HR), and the amount of bleeding until peak SI and peak HR were retrospectively examined and analyzed. We used the receiver operating characteristic analysis to assess the diagnostic value of peak SI and peak HR for judging abnormal obstetric bleeding.

RESULTS

Peak SI and peak HR were significantly related to the amount of bleeding up to peak SI and up to peak HR. The cutoff values of peak SI with blood loss volumes above 500 ml, 1000 ml, and 1500 ml were 0.77, 0.76, and 0.99, respectively. The cutoff values of peak HR with blood loss volumes above 500 ml, 1000 ml, and 1500 ml were 97, 98, and 103, respectively.

CONCLUSION

In cases of pregnant women complicated with HDP, both SI and HR were probably useful indicators in the management of postpartum blood loss. Further prospective trials are warranted to confirm these results.

Maternal death analysis based on data from the nationwide registration system in Japan (2010-2018)

The maternal mortality rate in Japan was 3.5 per 100 000 live births in 2017, similar to that reported in other developed countries. To reduce the number of maternal deaths, a Japanese nationwide registration and analysis system was implemented in 2010. Between January 2010 and April 2018, 367 maternal deaths were reported. Among them, by reviewing 80 autopsy records, the direct obstetric causes of death were identified in 52 women. The major causes of deaths were amniotic fluid embolism and acute pulmonary thromboembolism. The other 26 maternal deaths were associated with indirect obstetric causes including invasive Group A Streptococcus infection, aortic dissection, cerebral stroke and cardiomyopathies. This review highlights the importance of autopsy in maternal deaths. On analyzing 42 autopsy specimens obtained from registered cases of maternal death during 2012-2015, the 36% of causes of death by autopsy were discordant with the clinical diagnosis. Moreover, of the 38% of non-autopsied maternal death, the cause of death could not be clarified from the clinical chart. We emphasized that detailed autopsies are necessary to clarify the precise pathologic evidence related to pregnancy and delivery, especially causes of unexpected death such as amniotic fluid embolism.

Embolization of dural arteriovenous fistula during twin pregnancy - A case report and literature review

BACKGROUND

Several literature reviews have suggested that pregnancy may trigger the formation of dural arteriovenous fistulae (DAVF). However, few case reports have described DAVF discovered during pregnancy, and treatment strategies remain largely unknown.Case description: A 28-year-old primigravid woman without any medical history of note presented to our hospital for natural twin conception. She started to feel left-sided pulsatile tinnitus in 23 weeks of gestation. Magnetic resonance imaging of the head raised suspicion of left cavernous sinus DAVF with leptomeningeal venous drainage. Considering the risk of intracerebral hemorrhage due to the increased cardiac output in the third trimester of a twin pregnancy, we performed transarterial embolization for the DAVF, which was successfully achieved without complications in 28 weeks of gestation. Tinnitus resolved immediately after the procedure, and the postoperative course proved uneventful. Both fetuses were safely delivered by cesarean section on 37 1/7 weeks of gestation.

CONCLUSIONS

We encountered a case of cavernous sinus DAVF during a twin pregnancy. This case suggests that hemodynamic shift due to pregnancy has potential to cause higher shunt flow in an arteriovenous fistula. The timing of treatment should be determined in consideration of the hemodynamic change in the course of pregnancy. If X-ray exposures and iodine contrast media are appropriately managed, endovascular intervention is one treatment option, even during pregnancy.

Cerebrovascular disease in women

Cerebrovascular disease is a major cause of morbidity, mortality, and disability in women. The spectrum of disease differs between men and women, with women being particularly vulnerable to certain conditions, especially during specific periods of life such as pregnancy. There are several unique risk factors for cerebrovascular disease in women, and the influence of some traditional risk factors for stroke is stronger in women. Moreover, disparities persist in representation of women in clinical trials, acute intervention, and stroke outcomes. In this review, we aimed to explore the epidemiology, etiologies, and management of cerebrovascular disease in women, highlighting some of these differences and the growing need for sex-specific management guidelines and health policies.

Hospital transfer for patients with postpartum hemorrhage in Yokohama, Japan: a single‐center descriptive study

Aim

To describe the transport time and timing of transfer of patients with postpartum hemorrhage to a tertiary care institution in an urban area.

Methods

We included patients with postpartum hemorrhage transferred to our hospital from a perinatal care facility. We defined transfer time as the time between the referring physician's request for transfer and the patient's arrival at our hospital. We examined transfer time and its breakdown, the shock index before and after transfer, and the prognosis.

Results

Overall, 79 patients with postpartum hemorrhage were transported to our hospital within a median (interquartile range) of 53 min (47–63 min). In 70 cases (89%), the request for transport was made before the shock index reached 1.5, and two cases had cardiac arrest during transport.

Conclusions

Most patients who were transferred to our hospital were transferred according to the criteria recommended by the guideline. However, the occurrence of cardiac arrest during transport indicates the need to shorten the time from transfer requests to emergency calls by strengthening cooperation with regional perinatal care facilities.

Impact of a Psychiatric Nurse Specialist as a Liaison for Pregnant Women with Mental Disorders

A number of scholarly reports have shown the importance of mental health care during pregnancy, especially for women with mental disorders. Nevertheless, the postpartum mortality rate due to mental disorders has been a serious issue in Japan. Therefore, since January 2015, our hospital has implemented a liaison system in which one psychiatric nurse specialist contributes to perinatal care. The aim of this study is to explore the impacts of a psychiatric nurse specialist as a liaison for pregnant women with mental disorders. More specifically, the investigation was retrospectively performed from January 2011 to December 2019 using medical records from a single university medical hospital in Japan. Participants comprised pregnant women with mental disorders. Of the 4,066 total deliveries completed during the study period, 152 women were detected as being exposed to the liaison system (2015-2019), while 92 were recognized as controls (2011-2014). We then conducted a comparative analysis between those who were exposed to the liaison system and the control group. Except for Apgar scores taken five minutes after birth, there were no intergroup differences in the patient characteristics or perinatal psychiatric outcomes. We found that the liaison system was associated with an increased rate of referral to the local public health center (p = 0.003). The system also significantly delayed the time at which patients first visited a psychiatrist because a psychiatric nurse could determine the urgency through interviews with the patients. Overall, our results suggest that the liaison system is helpful for pregnant women with mental disorders.

Summary of clinically diagnosed amniotic fluid embolism cases in Korea and disagreement with 4 criteria proposed for research purpose

OBJECTIVE

This study aimed 1) to investigate the clinical characteristics of amniotic fluid embolism (AFE) cases clinically diagnosed by maternal fetal medicine (MFM) specialists in Korea, 2) to check the disagreement with 4 recently proposed criteria by the Society for Maternal-Fetal Medicine (SMFM) for research purpose, and 3) to compare maternal outcomes between cases satisfying all 4 criteria and cases with at least 1 missing criterion.

METHODS

This study included 12 patients clinically diagnosed with AFE from 7 referral hospitals in Korea. We collected information, including maternal age, symptoms of AFE, the amount of transfusion, and maternal mortality.

RESULTS

The median maternal age was 33 years (range, 28-40 years). Regarding symptoms, cardiovascular arrest, hypotension, respiratory compromise, clinical coagulopathy, and neurologic signs were observed in 41.7%, 83.3%, 83.3%, 100%, and 66.7% of the cases, respectively. Among the 12 cases, 5 women died and 2 suffered severe neurologic disability, showing an intact survival rate of 41.7%. Disagreement with all 4 criteria proposed by the SMFM was found in 66.7% of the cases, due to the lack of criteria for disseminated intravascular coagulation or strict onset time (<30 minutes after delivery). There was no difference in maternal mortality and the amount of transfusion between cases satisfying all 4 criteria and cases with at least 1 missing criterion.

CONCLUSION

Two-thirds of clinically confirmed AFE cases did not satisfy all 4 criteria proposed by the SMFM, despite similar rates of maternal mortality with cases satisfying all 4 criteria. Our study suggests that there may be some discrepancy between the clinical diagnosis of AFE and the recent diagnostic criteria proposed by the SMFM for research purpose.

Predictive factors for secondary postpartum hemorrhage: a case-control study in Japan

BACKGROUND

Secondary postpartum hemorrhage (PPH) is defined as excessive vaginal blood loss occurring between 24 h and 6-12 weeks after birth. The incidence of secondary PPH varies from 0.2% to 3.0%, and the peak incidence ranges from 1 to 2 weeks postpartum. There is no clinical evidence regarding the cause of secondary PPH. Therefore, this study aimed to determine the predictive factors for secondary PPH in an Asian population.

METHODS

A case-control study was performed. The clinical data of 25 secondary PPH patients who had been admitted to our hospital between June 2012 and January 2019 were obtained for this study. Control patients (n = 100) were selected from pregnant women who delivered at the hospital during the same period; they were matched to secondary PPH patients using propensity score matching to adjust for maternal age at delivery, parity, and the use of assisted reproductive technology (ART). A multiple logistic regression analysis was used to determine the predictive factors for secondary PPH.

RESULTS

The median maternal age was 34 years (range, 24-42 years); 85 (68.0%) women were nulliparous, 31 (24.8%) used ART, and 116 (92.8%) had term deliveries. Immediate PPH (adjusted odds ratio [OR], 2.84; 95% confidence interval [CI], 1.04-7.75) and manual removal of the placenta (adjusted OR, 6.14; 95% CI, 1.21-31.1) were associated with secondary PPH.

CONCLUSION

Increasing the awareness of the predictive factors for secondary PPH could play an important role in the recognition and treatment of postpartum morbidity.

Maternal Mortality: 10 Year Experience of a Tertiary Center in Turkey

We retrospectively evaluated five maternal mortality cases that occurred in our institution within the last 10 years. Rate of maternal mortality was 24.5 per 100000 live births. Maternal mortality causes were cardiopulmonary failure secondary to veno-occlusive disease, septic shock secondary to osteosarcoma, pulmonary thromboembolism secondary to metastatic breast cancer, septic shock secondary to cholecystitis, and postpartum hemorrhage secondary to Niemann-Pick disease. Four out of five cases were evaluated as indirect maternal mortality cases. Three out of five cases ended up with a healthy newborn, while other cases ended up with abortus and postpartum exitus.

Weekend and off-hour effects on the incidence of cerebral palsy: contribution of consolidated perinatal care

Objective

This study estimated the effects of weekend and off-hour childbirth and the size of perinatal medical care center on the incidence of cerebral palsy.

Methods

The cases were all children with severe cerebral palsy born in Japan from 2009 to 2012 whose data were stored at the Japan Obstetric Compensation System for Cerebral Palsy database, a nationally representative database. The inclusion criteria were the following: neonates born between January 2009 and December 2012 who had a birth weight of at least 2000 g and gestational age of at least 33 weeks and who had severe disability resulting from cerebral palsy independent of congenital causes or factors during the neonatal period or thereafter. Study participants were restricted to singletons and controls without report of death, scheduled cesarean section, or ambulance transportation. The controls were newborns, randomly selected by year and type of delivery (normal spontaneous delivery without cesarean section and emergency cesarean section) using a 1:10 case to control ratio sampled from the nationwide Japan Society of Obstetrics and Gynecology database.

Results

A total of 90 cerebral palsy cases and 900 controls having normal spontaneous delivery without cesarean section were selected, as were 92 cerebral palsy cases and 920 controls with emergent cesarean section. A significantly higher risk for cerebral palsy was found among cases that underwent emergent cesarean section on weekends (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.06–2.81) and during the night shift (OR 2.29, 95% CI 1.30–4.02). No significant risk was found among normal spontaneous deliveries on weekends (OR 1.63, 95% CI 0.97–2.73) or during the quasi-night shift (OR 1.26, 95% CI 0.70–2.27). Regional perinatal care centers showed significantly higher risk for cerebral palsy in both emergent cesarean section (OR 2.35, 95% CI 1.47–3.77) and normal spontaneous delivery (OR 2.92, 95% CI 1.76–4.84).

Conclusion

Labor on weekends, during the night shift, and at regional perinatal medical care centers was associated with significantly elevated risk for cerebral palsy in emergency cesarean section.

Severe Aneurysmal Subarachnoid Hemorrhage after Warning Headache during Pregnancy: A Case Report

BACKGROUND

Aneurysmal subarachnoid hemorrhage is a rare but important cause of maternal death during pregnancy.

CASE DESCRIPTION

A 34-year-old primigravida (31 weeks of pregnancy) with acute headache but no neurological deficits or neck stiffness was prescribed medication and returned home. Four weeks later she presented with severe headache and consciousness disturbance. She was admitted to our hospital, where she fell into a deep coma. Brain CT and three-dimensional CT angiography showed subarachnoid hemorrhage and a 5-mm right internal carotid-posterior communicating artery aneurysm. Fetal heart rate was 60 beats per minute. Emergent cesarean section and surgical clipping were performed. Intraoperative examination revealed that the aneurysm originated at the right posterior communicating artery. There were no postoperative neurological focal deficits. On postoperative day 13 she developed delayed cerebral ischemia of the right temporo-parieto-occipital lobe. She was discharged home 36 days after surgery with left hemianopsia. The infant was free of complications and was discharged at age 17 days.

CONCLUSIONS

A pregnant woman with severe headache should undergo brain CT or magnetic resonance imaging to rule out subarachnoid hemorrhage.

Maternal, infant, and perinatal mortality statistics and trends in Korea between 2009 and 2017

Objective

To provide updates on maternal, infant, and perinatal mortality using the national population data of South Korea between 2009 and 2017 and describe the mortality rate by target groups, timing, or causes of events to provide a basis for detecting vulnerable populations and ensuring timely medical and political interventions.

Methods

Pregnancy-related mortality in women, as well as deaths of infants, in South Korea was identified using population data from Statistics Korea. Records from death certificates, cremation reports on infant and fetal deaths, and the complementary cause-of-death investigation system were reviewed for the 2009–2017 period.

Results

A total of 461 maternal deaths, 11,717 infant deaths, and 12,249 perinatal deaths, including fetal deaths over 28 gestational weeks, were identified from 3,945,159 live births between 2009 and 2017. The maternal mortality ratio was 13.5 deaths per 100,000 live births in 2009 and decreased to 7.8 in 2017. Only the rate of deaths related to hypertensive disorders showed an increasing tendency. Both the infant and perinatal mortality rates improved (from 3.2 deaths per 1,000 live births in 2009 to 2.8 in 2017 and from 3.5 to 2.7, respectively). Among the external causes of infant mortality, assaults including homicides accounted for 25% (n=150), and this proportion was constant throughout the study period.

Conclusion

Overall improvements were observed in all maternal, infant, and perinatal mortality measures. In-depth analysis and interventions with respect to certain causes, such as hypertensive disorders in mothers or assaults in infants, should be considered priority issues.

Perinatal outcome in case of maternal death for cerebrovascular acute disorders: a nationwide study in Japan

OBJECTIVE

The goal of this study is to find clues to improve perinatal outcomes in the case of cerebrovascular acute disorders during pregnancy.

STUDY DESIGN

We analyzed 35 cases of cerebrovascular diseases related to maternal deaths in Japan those that occurred during pregnancy and reported to the Committee of the Ministry of Health, Labor, and Welfare from 2010 to 2018.

RESULTS

Cerebrovascular acute disorders occurred at 34.6 ± 6.6 gestational weeks. There were seven intrauterine fetal deaths (IUFD), and eight cases showed neonatal asphyxia with umbilical arterial pH between 6.7 and 7.0 (asphyxia cases, n = 15). In two of eight newborns, brain hypothermia therapy was given, and all survived without neurological sequelae. Maternal dyspnea was significantly related to severe prolonged decelerations of the fetus (p < .05), and asphyxia cases (p < .005). Median time from maternal onset to delivery (OD time) was significantly longer in asphyxia cases than in the non-asphyxia cases (84 vs 29 min, p < .05). OD time over 30 min was significantly related to the antepartum occurrence, cervical dilatation <5 cm (p < .05), onset outside of the hospital (p < .001), and maternal transfer before delivery (p < .001).

CONCLUSION

More than 40% of cases experienced fetal asphyxia, and 20% ended in IUFD in maternal deaths related to cerebrovascular acute disorders. Maternal respiratory support and rapid delivery would be the keys to improve perinatal outcomes in case of cerebrovascular acute disorders during pregnancy.

Implementation assessment in confidential enquiry programmes: A scoping review

BACKGROUND

Response should be a key part of maternal death surveillance and response (MDSR) programmes, which include confidential enquiries into maternal deaths. The programmes investigate avoidable factors in maternal deaths and make recommendations for improving maternity care. There is a gap in information on how these recommendations are transformed into practice.

OBJECTIVE

To explore the methods used to assess the implementation status of recommendations made in confidential enquiries into maternal deaths and other health outcomes.

DATA SOURCES

We searched PubMed, Web of Science, CINAHL, and Google Scholar databases and general web for grey literature using the "Arksey and O'Malley framework" in all major scientific databases and search engines.

STUDY SELECTION AND DATA EXTRACTION

An initial screening was followed by extraction of information using a data chart. Variables in the chart were based on the response component of maternal death and surveillance systems.

SYNTHESIS

Information collected was summarised using content analysis method.

RESULTS

We reviewed 13 confidential enquiry systems into maternal deaths. Many confidential enquiries into maternal deaths published reports with their recommendations and dissemination often involved national-level scientific presentations. Only five reports provided strategies for implementing the recommendations. Follow-up of previous recommendations was routinely published in only two reports. However, impact assessment of recommendations on other health outcomes was found only in the UK.

CONCLUSION

There is a gap in monitoring the response generated by confidential enquiries into maternal deaths. Actions to develop this are therefore needed.

Amniotic fluid embolism syndrome: analysis of the Unites States International Registry

BACKGROUND

Incidence, risk factors, and perinatal morbidity and mortality rates related to amniotic fluid embolism remain a challenge to evaluate, given the presence of differing international diagnostic criteria, the lack of a gold standard diagnostic test, and a significant overlap with other causes of obstetric morbidity and mortality.

OBJECTIVE

The aims of this study were (1) to analyze the clinical features and outcomes of women using the largest United States-based contemporary international amniotic fluid embolism registry, and (2) to investigate differences in demographic and obstetric variables, clinical presentation, and outcomes between women with typical versus atypical amniotic fluid embolism, using previously published and validated criteria for the research reporting of amniotic fluid embolism.

MATERIALS AND METHODS

The AFE Registry is an international database established at Baylor College of Medicine (Houston, TX) in partnership with the Amniotic Fluid Embolism Foundation (Vista, CA) and the Perinatology Research Branch of the Division of Intramural Research of the NICHD/NIH/DHHS (Detroit, MI). Charts submitted to the registry between August 2013 and September 2017 were reviewed, and cases were categorized into typical, atypical, non-amniotic fluid embolism, and indeterminate, using the previously published and validated criteria for the research reporting of AFE. Demographic and clinical variables, as well as outcomes for patients with typical and atypical AFE, were recorded and compared. Student t tests, χ2 tests, and analysis of variance tables were used to compare the groups, as appropriate, using SAS/STAT software, version 9.4.

RESULTS

A total of 129 charts were available for review. Of these, 46% (59/129) represented typical amniotic fluid embolism and 12% (15/129) atypical amniotic fluid embolism, 21% (27/129) were non-amniotic fluid embolism cases with a clear alternative diagnosis, and 22% (28/129) had an uncertain diagnosis. Of the 27 women misclassified as an amniotic fluid embolism with an alternative diagnosis, the most common actual diagnosis was hypovolemic shock secondary to postpartum hemorrhage. Ten percent (6/59) of the women with typical amniotic fluid embolism had a pregnancy complicated by placenta previa, and 8% (5/61) had undergone in vitro fertilization to achieve pregnancy. In all, 66% (49/74) of the women with amniotic fluid embolism reported a history of atopy or latex, medication, or food allergy, compared to 34% of the obstetric population delivered at our hospital over the study period (P < .05).

CONCLUSION

Our data represent a series of women with amniotic fluid embolism whose diagnosis has been validated by detailed chart review, using recently published and validated criteria for research reporting of amniotic fluid embolism. Although no definitive risk factors were identified, a high rate of placenta previa, reported allergy, and conceptions achieved through in vitro fertilization was observed.

Acute inflammation in the uterine isthmus coincides with postpartum acute myometritis in the uterine body involving refractory postpartum hemorrhage of unknown etiology after cesarean delivery

Uterine atony is a major cause of postpartum hemorrhage. We recently proposed the new histological concept of postpartum acute myometritis (PAM) for the pathophysiology of refractory uterine atony of unknown etiology, which is characterized by the diffuse activation of mast cells and the complement system as well as the massive infiltration of macrophages and neutrophils into the uterine body. We herein focused on the uterine isthmus just adjacent to the body. The isthmus becomes significantly elongated throughout pregnancy. It is composed of myocytes and fibroblasts with an extracellular matrix that forms a passive lower segment during labor. The aim of this study was to histologically examine the uterine isthmus in cases of PAM in the uterine body. Under the amniotic fluid embolism-registry program in Japan, we selected PAM cases from uterine samples obtained by cesarean hysterectomy and delivered to us for analyses between 2011 and 2017. Control tissues were collected during elective cesarean section. We investigated the isthmus tissues of these cases and performed immunohistochemistry for inflammatory cell markers, i.e. neutrophil elastase, mast cell tryptase, CD68, CD3, and C5a receptor (C5aR). The numbers of tryptase-positive degranulating mast cells, elastase-positive neutrophils, CD68-positive macrophages, and C5aR-positive cells in the isthmus were significantly higher in uteri with PAM in the body than in controls without PAM. CD3 was negative in both groups. In conclusion, inflammation and an anaphylactoid reaction were histologically detected not only in the uterine body, but in the isthmus among cases of refractory PPH of unknown etiology after cesarean section.

Risk Factors for Cardiovascular Events among Pregnant Women with Cardiovascular Disease

Objective Cardiovascular disease increases the risk of maternal mortality. This study examined the risk factors for cardiovascular events in pregnant women with cardiovascular disease. Methods This was a case-control study conducted in 2 phases at Japanese maternal and fetal care centers. The primary survey, using an interviewer-administered questionnaire, investigated whether the institutions had managed pregnant women with cardiovascular disease from April 2014 to March 2016. From 424 individual facilities surveyed, 135 facilities were found to have experience in managing pregnant women. In the secondary survey, the 135 institutions were asked to complete a web-based questionnaire, which collected detailed clinical information about cases, including cardiovascular disease, cardiovascular events, maternal background, and the perinatal outcome. Results Information on 302 pregnant women with cardiovascular disease was collected. None of the 302 patients died. There were 25 women with cardiovascular events (cardiovascular event group) and 277 women without cardiovascular events (non-cardiovascular event group); the two groups were compared. No significant differences were found in the perinatal outcomes. Medication use before pregnancy was identified as a risk factor for cardiovascular events (adjusted odds ratio, 23.28; 95% confidence interval, 8.15-66.47; p<0.001). In pregnant women with cardiovascular disease, New York Heart Association (NYHA) functional class II or III before pregnancy was associated with a higher risk of cardiovascular events in comparison to NYHA functional class I (p<0.001 for both). Conclusion Medication use before pregnancy and NYHA functional class >I were risk factors for cardiovascular events in pregnant women with cardiovascular disease.