Update on Maternal Mortality Ob/ Gyne Rotation: Internship 2003

1. Update on Maternal MortalityOb/ Gyne Rotation:Internship 2003 Dr. Khalid Yarouf (Intern) 4MedStudents.com

2. Introduction • Maternal and infant mortality are basic health indicators that reflect a nation’s 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 1950’s 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. Con’t Introduction

6. Con’t 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. • Japan’s 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. Con’t (TED) • PULMONARY EMBOLISM (PE)  more serious, symptoms: chest pain, SOB, hemoptysis (coughing blood), and if large, severe hypoxia & collapse.

9. Con’t (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. Con’t (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. Con’t (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. Con’t (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. Con’t (PE) Table 2. Commonest symptoms and physical signs in PE.

15. Con’t (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. Con’t (Investig. of PE)

18. Con’t (Investig. of PE) • Ventilation-perfusion (V/Q) scanning of the lungs: for establishing the diagnosis of PE.

19. Con’t (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. Con’t (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. Con’t (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. Con’t 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. Con’t 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. Con’t 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