Update on Maternal Mortality Ob/ Gyne Rotation: Internship 2003

1
Update on Maternal MortalityOb/ Gyne
RotationInternship 2003

• Dr. Khalid Yarouf (Intern)

4MedStudents.com
2
Introduction

• Maternal and infant mortality are basic health
  indicators that reflect a nations health status.
  
• Maternal deaths are defined as those deaths that
  occurred during a pregnancy or within 42 days of
  the end of a pregnancy and for which the cause of
  death was listed as a complication of pregnancy,
  childbirth, or puerperium.
• The maternal mortality rate is the number of
  maternal deaths per 100,000 live births.
• In the US, the annual maternal mortality ratio
  remained approx. 7.5 maternal deaths per 100,000
  live births during 1982-1996.

3
Table 1. Causes of Maternal Death in the US in
1993. Modified from Monthly Vital Statistics
Report, DHHS-PHS publ No. 95-1120, vol 44, pp
1-88, 1995.
4
Cont Introduction

• More than ½ of all maternal deaths can be
  prevented through early diagnosis and appropriate
  medical care of pregnancy complications.
  Hemorrhage, PIH, infection, and ectopic pregnancy
  continue to account for most (59) maternal
  deaths.
• Maternal mortality ratios remained higher for
  black women than for white women.
• Maternal mortality has fallen from 70 per 100,000
  in the 1950s to 11 per 100,000 in 1994-1996 in
  the UK. The main reduction has been in direct
  causes, particularly those related to abortion,
  following the liberalization of abortion laws in
  1968.

5
Cont Introduction
6
Cont Introduction

• Some States in the US reestablished maternal
  mortality review committees to identify
  interventions that may have an impact on reducing
  maternal mortality. These committees review
  various factors that may have contributed to
  maternal deaths, including the quality of medical
  care and systemic problems in the health-care
  delivery system.
• Japans maternal mortality rate is higher than
  that of other developed countries.
• Japanese conducted a cross-sectional study of
  maternal deaths between 1991 and 1992.
• Objectives to identify causes of maternal
  mortality in Japan, examine attributes of
  treating facilities associated with maternal
  mortality, and assess the preventability of such
  deaths.
• Conclusion
• Maternal mortality was 9.5 per 100,000 births.
• Inadequate obstetric and anesthetic services and
  laboratories facilities are associated with
  maternal mortality.

7
Venous thromboembolic disease

• Venous thromboembolic disease (TED) occurs when a
  blood clot forms in a deep vein, usually in a leg
  ? forming a DVT, which may cause pain swelling.
• This is very rarely fatal, but if part of the
  clot breaks off it may be carried by the blood to
  the lungs ? blocks a blood vessel there ?

8
Cont (TED)

• PULMONARY EMBOLISM (PE) ? more serious, symptoms
  chest pain, SOB, hemoptysis (coughing blood), and
  if large, severe hypoxia collapse.

9
Cont (TED)

• Serious long-term maternal morbidity, including
  venous insufficiency, often manifests as a
  painful often ulcerating leg, due to
  compromised blood flow to limb.

10
Cont (TED)

• TED is the leading cause of maternal mortality in
  developed countries and most of the maternal
  deaths caused by it are due to PE.
• There is an increasing chance of a thromboembolic
  event (DVT or PE) occurring during pregnancy and
  the immediate postnatal period, because of
  chemical changes in the blood and a reduction in
  the velocity of blood flow in the lower limbs.
  However, the best recent estimate of TED
  incidence is from a Swedish study (1999) which
  showed that it is rare during pregnancy the
  immediate postnatal period.

11
Cont (TED)

• Some groups of women have a higher risk of
  developing TED in association with pregnancy.
  Specific risk factors that have been identified
  include
• Operative delivery.
• Having had 1 previous episodes of TED.
• FHx of TED.
• Having inherited or acquired thrombophilia
  (condition that predisposes people to developing
  thromboses).
• Obesity.
• Greater maternal age.
• Higher parity.
• Prolonged immobilization.

12
Cont (TED)

• The size of the increases in risk attributable to
  these factors are generally poorly quantified,
  e.g. for women who had previous thrombosis, the
  risk of TED has been estimated as ? 2.4 if
  antenatal thromboprophylaxis is not used (95
  confidence interval 0.2 6.9).

13
Pulmonary Embolism (PE)

• The mortality and morbidity rates from venous
  thromboembolism are best described in 2 words
  substantial and unacceptable !
• Clinical Features
• The presentation of PE may vary from a sudden
  onset of catastrophic hemodynamic collapse to
  gradually progressive dyspnea. The diagnosis of
  PE should be sought actively in patients with
  respiratory symptoms unexplained by an alternate
  diagnosis. The symptoms of PE are nonspecific
  therefore, a high index of suspicion is required,
  particularly when a patient has risk factors,
  which include recent surgery, immobility, or a
  hypercoagulable state.

14
Cont (PE)
Table 2. Commonest symptoms and physical signs in
PE.
15
Cont (PE)

• Massive PE
• Large emboli compromise sufficient pulmonary
  circulation ? circulatory collapse and SHOCK.
• The patient has hypotension appears weak, pale,
  sweaty, and oliguric and develops impaired
  mentation.

16
Investigations of PE

• Arterial blood gases (ABG) ? characteristically
  reveal hypoxemia, hypocapnia, and respiratory
  alkalosis.
• Imaging studies
• Chest radiograph Initially, the chest
  radiography findings commonly are normal.
  However, in later stages, the x-ray film may show
  radiographic signs that include a Westermark sign
  (dilatation of pulmonary vessels and a sharp
  cutoff), atelectasis, a small pleural effusion,
  and an elevated diaphragm.

17
Cont (Investig. of PE)
18
Cont (Investig. of PE)

• Ventilation-perfusion (V/Q) scanning of the
  lungs for establishing the diagnosis of PE.

19
Cont (Investig. of PE)

• Color-flow Doppler imaging and compression US
  have ? sensitivity specificity.
• Pulmonary angiography remains the criterion
  standard for the diagnosis of PE.
• MRI 85 sensitive, 96 specific for central,
  lobar, and segmental emboli MRI is inadequate
  for the diagnosis of subsegmental emboli.

20
Cont (Investig. of PE)

• ECG
• Commonest abnormalities of PE are tachycardia and
  nonspecific ST-T wave abnormalities. These
  findings are not sensitive or specific enough to
  aid in Dx of PE.

21

• The classic finding of right-heart strain
  demonstrated by an S1-Q3-T3 pattern is observed
  in only 20 of patients with proven PE.

22
Cont (PE)

• Mx
• Immediate full anticoagulation is mandatory for
  all patients suspected to have DVT or PE.
• Prognosis
• Death from a massive PE is second only to the
  sudden cardiac death. Autopsy studies of
  hospitalized patients have shown approx. 80 of
  these patients died from massive PE.
• Approx. 10 of patients who develop PE die within
  the first hour, and 30 die subsequently from
  recurrent embolism.

23
Thromboprophylaxis during antenatal and postnatal
period

• Women who have particular risk factors for the
  development of TED are often given
  thromboprophylaxis during the antenatal or
  postnatal period or both. Pharmacological and
  non-pharmacological methods have been used.
• Pharmacological methods
• Use anti-coagualnts ? help prevent blood
  clotting.
• Include Heparin, warfarin, aspirin, hydroxyethyl
  starch.
• Non-pharmacological methods
• Keep blood moving in lower limbs ? help prevent
  clot formation.
• Include stockings, pneumatic compression, early
  mobilization and surveillance.

24
Cont Thromboprophylaxis

• The duration of prophylaxis varies depending on
  the risk factor. Women who have had a previous
  episode of TED may receive long-term antenatal
  prophylaxis as well as prolonged postnatal
  prophylaxis, while women undergoing delivery by
  C-section may receive only postnatal prophylaxis
  for a few days.
• All the current guidelines mentioned above are
  based on expert opinion only, rather than high
  quality evidence from randomized trials.

25
Cont Thromboprophylaxis

• Cochrane Reviewers searched for randomized
  Controlled Trials (RCTs) concerning this issue to
  determine the effects of thromboprophylaxis in
  association with pregnancy in women who are
  pregnant or have recently delivered on the
  incidence of venous thromboembolic disease and
  side effects.
• Recent Cochrane Review shows that the evidence
  available from RCTs is clearly inadequate as a
  basis for clinical decisions. Guidelines for
  thromboprophylaxis in pregnancy and the postnatal
  period have been produced by the Royal College of
  Obstetricians and Gynaecologists (RCOG) in the
  UK, the American College of Chest Physicians, and
  the British Society for Haematology. Because of
  the lack of RCTs, these guidelines are based
  mainly on expert opinion rather than high quality
  evidence.

26
Cont Thromboprophylaxis

• Conclusions
• Concerning implications for practice, the
  information currently available is insufficient
  to make any recommendations for practice.
• Implications for research there is a clear need
  for rigorously large scale RCTs with sample sizes
  sufficiently large to assess the effects of
  methods of thromboprophylaxis on rare outcomes
  such as thromboembolic events. No trials have yet
  assessed non-pharmacological methods of
  thromboprophylaxis during pregnancy and the
  postnatal period.

27
Discussion
28
Montreal (Canada) Jardin Boutanique October 2002
29
Thanks for listening