Trauma: the leading cause of maternal death.

The records of the Cook County Medical Examiner were reviewed for the period January, 1986, to December, 1989. Ninety-five maternal deaths were identified. The causes of maternal death were categorized as direct maternal, indirect maternal, or nonmaternal. Direct maternal causes of death (18.9%) were the result of complications of pregnancy, labor, delivery, or its management. Indirect maternal causes of death (12.6%) occurred when pre-existing health problems were exacerbated by pregnancy. All other maternal deaths were the result of nonmaternal causes. Nonmaternal causes of maternal death were further classified as traumatic or nontraumatic. Traumatic maternal deaths (46.3%) were attributed to homicide in 57% and suicide in 9%. The mechanism of injury in traumatic maternal deaths included gunshot wounds (22.7%), motor vehicle crashes (20.5%), stab wounds (13.6%), strangulation (13.6%), blunt head injuries (9.1%), burns (6.8%), falls (4.5%), toxic exposure (4.5%), drowning (2.3%), and iatrogenic injury (2.3%). Trauma was therefore the leading cause of maternal death, accounting for 46.3% of deaths in this series.     

Vascular malformations and pregnancy

Between January 1975 and June 1989, 240 patients with cerebral vascular malformations were treated at Henry Ford Hospital. In 16 of the patients, the treatment was influenced by pregnancy. Eleven of the patients presented with hemorrhage, four with seizures, and one with hydrocephalus. There were no maternal or fetal deaths in the patients presenting with seizure or hydrocephalus. There were two maternal deaths and one fetal death among the cases presenting with hemorrhage. In the patients with seizure or hydrocephalus, the pregnancy was brought to term and obstetric indications used to determine the time and method of delivery. Hydrocephalus was treated by shunting, and seizures with medication. Antiepileptic drug levels fluctuate in pregnancy and hence were closely monitored to ensure therapeutic levels. Vascular malformations are the most common cause of subarachnoid hemorrhage in pregnancy. The risk of rebleed in the same pregnancy is about 27%. If an arteriovenous malformation ruptures during pregnancy and the patient's condition deteriorates, appropriate emergency surgery should be done. In stable patients, our policy has been to bring the pregnancy to term and then electively perform a craniotomy to excise the arteriovenous malformation.     

A series of anesthesia-related maternal deaths in Michigan, 1985-2003

BACKGROUND: Maternal Mortality Surveillance has been conducted by the State of Michigan since 1950, and anesthesia-related maternal deaths were most recently reviewed for the years 1972-1984. METHODS: Records for pregnancy-associated deaths between 1985 and 2003 were reviewed to identify 25 cases associated with a perioperative arrest or major anesthetic complication. Four obstetric anesthesiologists independently classified these cases, and disagreements were resolved by discussion. Precise definitions of anesthesia-related and anesthesia-contributing maternal death were constructed. Anesthesia-related deaths were reviewed to identify the chain of medical errors or care management problems that contributed to each patient death. RESULTS: Of 855 pregnancy-associated deaths, 8 were anesthesia-related and 7 were anesthesia-contributing. There were no deaths during induction of general anesthesia. Five resulted from hypoventilation or airway obstruction during emergence, extubation, or recovery. Lapses in either postoperative monitoring or anesthesiology supervision seemed to contribute to 5 of the 8 anesthesia-related deaths. Other characteristics common to these cases included obesity (n=6) and African-American race (n=6). CONCLUSIONS: The 8 anesthesia-related and seven anesthesia-contributing maternal deaths in Michigan between 1985 and 2003 illustrate three key points. First, all anesthesia-related deaths from airway obstruction or hypoventilation took place during emergence and recovery, not during the induction of general anesthesia. Second, system errors played a role in the majority of cases. Of concern, lapses in postoperative monitoring and inadequate supervision by an anesthesiologist seemed to contribute to more than half of the deaths. Finally, this report confirms previous work that obesity and African-American race are important risk factors for anesthesia-related maternal mortality.     

Maternal mortality in southern Africa, 1980-1982. Part I. Pregnancy can be lethal

Statistics regarding the number of births and maternal deaths during the 3-year period 1980-1982, received from 267 hospitals in southern Africa, are presented. Although 812 maternal deaths were recorded, sufficient information for adequate analysis of epidemiological factors (age and parity), cause of death and avoidable factors was available in only 737. The maternal mortality rate was 8.3/10,000. Six hundred and sixty deaths (89.6%) were classified as direct obstetric death. Two hundred and twenty-nine deaths (31%) occurred in women experiencing their first pregnancy. Avoidable factors could be shown to operate in 407 deaths. Important factors identified were that the patient presented very late for antenatal or intrapartum care, that inadequate therapy was administered and that therapy deviated from the accepted norm. Fetal and neonatal loss was high: only 271 infants survived.     

A Series of Anesthesia-related Maternal Deaths in Michigan, 1985-2003

Background: Maternal Mortality Surveillance has been conducted by the State of Michigan since 1950, and anesthesia-related maternal deaths were most recently reviewed for the years 1972-1984.

Methods: Records for pregnancy-associated deaths between 1985 and 2003 were reviewed to identify 25 cases associated with a perioperative arrest or major anesthetic complication. Four obstetric anesthesiologists independently classified these cases, and disagreements were resolved by discussion. Precise definitions of anesthesia-related and anesthesia-contributing maternal death were constructed. Anesthesia-related deaths were reviewed to identify the chain of medical errors or care management problems that contributed to each patient death.

Results: Of 855 pregnancy-associated deaths, 8 were anesthesia-related and 7 were anesthesia-contributing. There were no deaths during induction of general anesthesia. Five resulted from hypoventilation or airway obstruction during emergence, extubation, or recovery. Lapses in either postoperative monitoring or anesthesiology supervision seemed to contribute to 5 of the 8 anesthesia-related deaths. Other characteristics common to these cases included obesity (n = 6) and African-American race (n = 6).     

Risk factors associated with cardiac surgery during pregnancy

BACKGROUND: This study is aimed at analyzing risk factors for fetal and maternal mortality in cardiac surgery during pregnancy. METHODS: Seventy-four pregnant women underwent cardiac surgery and 58 (78.3%) were followed. The most frequent pathology was valve disease (93.2%). Mitral valve disease was the most prevalent (72.9%), and mitral commissurotomy or replacement was required in 78% of the cases. Most were in functional class III or IV and mean gestational age was 22 weeks. RESULTS: There was functional class improvement after surgery (91% into class I or II), and 70.4% were restored to sinus rhythm. Twenty percent required reoperation. There were five maternal deaths (8.6%) and 11 fetal deaths (18.6%). Several aspects were considered as contributing risk factors for maternal mortality, such as the use of vasoactive drugs and other preoperative medications, age, kind of surgery, reoperation, and functional class. Functional class was the factor that predicted higher risk for maternal death. As to fetal mortality, several factors played a role, such as maternal age more than 35 years, functional class, reoperation, emergency surgery, type of myocardial protection, and anoxic time. CONCLUSIONS: Cardiac surgery during pregnancy is associated with acceptable maternal and fetal mortality rates. These rates may be even lower if the factors mentioned above are maintained under control.     

Trauma during pregnancy: a situation pregnant with danger

Trauma in pregnancy is currently a leading cause of non-pregnancy-related maternal death, and maternal death remains the most common cause of fetal demise. The most common etiologies of trauma in pregnancy include transportation accidents, falls, violent assaults, and burn injuries. Head and neck injuries and hemorrhagic shock account for most maternal deaths secondary to trauma. Women of childbearing age are among the population at greatest risk for trauma. The pregnant trauma victim presents a unique spectrum of challenges to the health care team. Expeditious maternal resuscitation is the most effective method of fetal resuscitation. The management of pregnant trauma victims requires the anesthesiologist, the obstetrician and the trauma surgeon to consider and understand the unique changes in anatomy and physiology that take place during pregnancy. This article reviews the current considerations for the optimal perioperative management of pregnant trauma victims.     

Maternal deaths at Pelonomi Hospital, Bloemfontein, 1980-1985. A survey of 81 consecutive cases

From 1 January 1980 to 31 December 1985, 81 maternal deaths occurred at Pelonomi Hospital, Bloemfontein; these were classified as direct obstetric-related (74 cases), indirect obstetric-related (6) and non-obstetric (1). The overall maternal mortality rate was 2.87 per 1000 deliveries, including deaths related to abortion and ectopic pregnancy, but excluding the non-obstetric death. Among booked patients the maternal mortality rate was 0.32 and among unbooked patients 11.13 per 1000 deliveries. The maternal mortality rate for patients from the Bloemfontein area was 0.72 per 1000. Puerperal sepsis and postabortal sepsis accounted for 45.7% of the deaths. Avoidable factors were considered to be present in 65 cases (80.2%).     

HIV/AIDS: impact on maternal mortality at the Johannesburg Hospital, South Africa, 1995-2001

This study investigated maternal mortality at the Johannesburg Hospital, a 1100-bed academic hospital in South Africa. Patient records were assessed retrospectively over two time periods: 1995/1996 and 2000/2001. Causes of death were noted and compared with national data. The two time periods were compared to identify disease patterns and the role of anaesthesia in maternal mortality. The maternal mortality ratios were respectively 183 and 354 per 100000 live births respectively. Hypertension in pregnancy was the leading cause of mortality in 1995/1996, accounting for 10 out of the 20 deaths, but was the second most common cause in 2000/2001 (6 out of 35). HIV/AIDS-associated disease was the leading cause of mortality in 2000/2001 (42.7%, increasing from 20% in 1995/1996) with pneumonia the commonest cause of death. The statistics at this hospital were consistent with the national trend of an increasing association with HIV/AIDS. No deaths were found to be directly attributable to anaesthesia in either of the time periods. There is a need for clearer documentation of HIV status in pregnancy and antiretroviral intervention strategies must be considered.     

Obstetric emergencies

The two most recent Confidential Enquiries into Maternal and Child Health reports, examining Maternal Mortality in the UK, demonstrate that haemorrhage, hypertensive disease, amniotic fluid embolus and sepsis remain the most important direct causes of death after thromboembolic disease. Cardiac disease is the most important indirect cause of maternal death. Substandard care is adjudged to have contributed to more than 50% of all maternal deaths, and the reports highlight the importance of multidisciplinary care. This article addresses some of the key issues in the management of obstetric emergencies and emphasizes the importance of multidisciplinary teamwork and fire drills.     

A survey of asthma mortality in patients between ages 35 and 64 in the Greater London hospitals in 1971.

We have examined the death certificates from all patients aged 35-64 years who were recorded as dying from asthma in Greater London Council hospitals in 1971. Of the 47 death certificates studied, nine suggested that the primary cause of death was not asthma. From the remaining 38 deaths we have obtained 36 case records and found that 15 deaths occurred outside hospital and another two patients died in hospital having been admitted in a stable state. We have examined the remaining 19 case records to find out the circumstances of death in patients with asthma who die in hospital. We have been unable to exclude the possibility that many of the deaths in hospital were avoidable. Assessment of severity in most patients was incomplete, as judged by a retrospective analysis of case records, and many of the patients would be regarded as having had insufficient treatment. Four patients did not receive corticosteroids and in a further three the dose given was small. No physiological assessment of airflow obstruction was made in over half the patients. A comparison with 19 survivors of an admission to hospital with asthma did not provide enough information to account for the deaths. The survivors were in hospital for a shorter period of time, were slightly less ill, and were given comparable treatment regimens. Both groups of patients were inadequately assessed, and sedatives were given to approximately 70% of all subjects studied. The deaths in hospital usually occurred suddenly in the early morning in general medical wards.     

Maternal deaths at Harare Maternity Hospital during 1983

There were 51 maternal deaths at Harare Maternity Hospital, Zimbabwe, during 1983, 25 among patients from the greater Harare area and 26 among patients referred from peripheral hospitals or clinics. The overall maternal mortality rate among patients within the greater Harare area was 56/100 000 (including deaths related to abortion). Among 'booked' patients the maternal mortality rate was 29/100 000. Puerperal sepsis, haemorrhage, post-abortal sepsis and hypertensive disease accounted for 78.4% of the deaths. Avoidable factors, considered to be present in 34 cases (66.7%), are discussed.     

Cardiovascular causes of death at Tshepong Hospital in 1 year, 1989-1990. A necropsy study.

Cardiovascular disease is the third most common cause of death in Tshepong Hospital in the western Transvaal, and the most common cause of death in patients older than 35 years. A prospective study was undertaken which included limited necropsies in 90 of the 167 cardiovascular disease deaths over 1 year. A reliable mortality pattern for cardiovascular deaths is described. Additionally, attention is paid to co-existing conditions. Conditions relating to cardiovascular disease, such as hypertension, benign hypertensive nephrosclerosis, atherosclerosis and obesity, were also evaluated. Cerebrovascular conditions were found in 32% of cardiovascular deaths. Intracerebral haemorrhage was found in 50% and cerebral infarction in 29% of cases. Fifty-seven per cent of cardiovascular deaths were due to cardiac conditions, the most common being pulmonary hypertension (31%), dilated cardiomyopathy and chronic rheumatic valvular disease (17% each) and hypertensive heart disease (14%). Forty-nine per cent of subjects were hypertensive, while 40% exhibited benign nephrosclerosis and only 3% of the examined vessels had signs of severe atherosclerosis. Tuberculosis was present in 13% of cases. The clinical diagnosis was the same as the final necropsy diagnosis in 38% of cases. These results emphasise the importance of performing necropsies to obtain reliable mortality statistics.     

Hemostatic hysterectomy in modern obstetrics

Haemostatic hysterectomies have been performed for the first time in the XIXth century to reduce the increased maternal mortality and associated morbidity. In Romania the main cause of death through direct obstetrical risk (DOR) is the haemorrhagic syndrome, with a value of 45% of the total number of deaths in the last 15 -16 years, a lot higher then the world average of 25% as evaluated by OMS. Among the deaths due to hemorrhagic syndrome 43% is held by antepartum haemorrhage (placenta praevia, utero-placental apoplexy) and 42% by postpartum haemorrhage. RESULTS: In the past 15 years (1990 - 2005) there have been studied 53,870 births, out of which only 60 have had haemostatic hysterectomy, representing 0.11% of the total number of births. The prevalence of haemostatic hysterectomy is only 1 in every 883 births as a result of surgical teams' efforts to preserve the uterus. The placental pathology (30%) is responsible for most of haemostatic hysterectomy indications. Out of 60 cases under study, none ended with maternal death, while 11 cases ended with fetal death (intrapartum or postpartum). CONCLUSIONS: Morbidity and maternal death can be reduced by effective prenatal care, by identifying high risk patients and by the possibility of caesarean section. Haemostatic hysterectomy remains, in essence, a life saving procedure!     

Maternal deaths associated with eclampsia in South Africa: Lessons to learn from the confidential enquiries into maternal deaths, 2005 - 2007

Eclampsia is the commonest direct cause of maternal death in South Africa. The latest Saving Mothers Report (2005-2007) indicates that there were 622 maternal deaths due to hypertensive disorders of pregnancy. Of these, 334 (55.3%) were due to eclampsia; of the eclamptic deaths, 50 were over the age of 35 years and 83 were under 20 years old. Avoidable factors involved patient related factors (mainly delay in seeking help), administrative factors (mainly delay in transport) and health personnel issues (mainly due to delay in referring patients). The major causes of death were cerebrovascular accidents and cardiac failure. The majority of deaths due to cardiac failure were due to pulmonary oedema. To reduce deaths from eclampsia, more attention must be given to the detection of pre-eclampsia; the provision of information on the advantages of antenatal care to the population at large and training of health professions in the management of obstetric emergencies.     

A multi-institutional study of factors associated with fetal death in injured pregnant patients.

HYPOTHESIS: Factors associated with fetal death in injured pregnant patients are related to increasing injury severity and abnormal maternal physiologic profile. DESIGN: A multi-institutional retrospective study of 13 level I and level II trauma centers from 1992 to 1996. MAIN OUTCOME MEASURE: Fetal survival. RESULTS: Of 27,715 female admissions, there were 372 injured pregnant patients (1.3%); 84% had blunt injuries and 16% had penetrating injuries. There were 14 maternal deaths (3.8%) and 35 fetal deaths (9.4%). The population suffering fetal death had higher injury severity scores (P<.001), lower Glascow Coma Scale scores (P<.001), and lower admitting maternal pH (P = .002). Most women who lost their fetus arrived in shock (P = .005) or had a fetal heart rate of less than 110 beats/min at some time during their hospitalization (P<.001). An Injury Severity Score greater than 25 was associated with a 50% incidence of fetal death. Placental abruption was the most frequent complication, occurring in 3.5% of patients and associated with 54% mortality. Cardiotrophic monitoring to detect potentially threatening fetal heart rates was performed on only 61% of pregnant women in their third trimester. Of these patients, 7 had abnormalities on cardiotrophic monitoring and underwent successful cesarean delivery. CONCLUSIONS: Fetal death was more likely with greater severity of injury. Cardiotrophic monitoring is underused in injured pregnant patients in their third trimester even after admission to major trauma centers. Increased use of cardiotrophic monitoring may decrease the mortality caused by placental abruption.     

Operative obstetric mortality at Harare Central Hospital 1992-1994: an anaesthetic view

A prospective review of anaesthetic-associated deaths (AAD) was undertaken at the maternity unit of Harare Central Hospital, Zimbabwe, for the triennium 1992-1994. AAD was defined as death within 24 h of anaesthesia or failure to regain consciousness. Three groups of avoidable factors (obstetric, anaesthetic and administrative) were considered, and a scoring system used to allocate one avoidability point for each death with avoidable factors. Out of 9833 operative procedures (91% under general anaesthesia) there were 22 AADs. Avoidable factors were identified in 17 deaths (77%). Seven deaths were directly attributable to anaesthesia. Haemorrhage was the commonest cause of death, accounting for 10 cases. Common factors, identified in all instances of substandard anaesthetic and obstetric care, were emergency cases and lack of senior involvement. The problems are discussed and also viewed in the context of overall maternal mortality (outcome period 42 days). The mortality data are compared with those from the UK and some hospitals in South Africa. It is concluded that improvements in resources, education, guidelines and monitoring are necessary if the mortality rate is to be reduced.     

Maternal and neonatal death associated with Eisenmenger's syndrome

Pregnancy in patients with Eisenmenger's syndrome is known to be associated with a high incidence of maternal and perinatal death. Complications can occur before and during parturition but are most hazardous in the early postpartum period. If the exact causes of maternal death remain in most instances unknown, hypovolemia with augmented pulmonary to systemic shunt, thromboembolism and cardiac arrythmias are often mentioned as the primary causes of mortality. We report the unsuccessful management of a pregnant patient with Eisenmenger's disease despite all possible precautions as reported in the literature had been taken. We discuss these precautions and more specifically the type of anesthesia that is best given, the prophylactic methods of anticoagulation and the benefit of monitoring techniques in the management of such complex pathologies.     

Anesthetic-related maternal mortality, 1954 to 1985

This is a population-based study of the safety of obstetrical anesthesia in the Commonwealth of Massachusetts between 1954 and 1985. We used data collected by the state Committee on Maternal Mortality, which was founded in 1941. There were a total of 37 maternal deaths during the study period due to anesthetic-related complications. During the same time period, there were 886 maternal deaths. Thus, anesthetic-related mortality comprised 4.2% of all deaths, and the mortality rate was 1.5 per 100,000 live births between 1955 and 1964, 1.5 per 100,000 live births between 1965 and 1974, and 0.4 per 100,000 live births between 1975 and 1984. In the first decade of this study, aspiration during administration of a mask anesthetic was the primary cause of death. During the second decade, cardiovascular collapse associated with regional anesthesia was the primary cause of death. During the last decade of this study, all deaths were associated with general endotracheal anesthesia. As a result of this study and having identified the changes in the standard of care in Massachusetts that led to the reduction in maternal mortality, we offer recommendations to further improve the safety of anesthesia for childbirth in this country.