Maternal Morbidity (maternal + morbidity)

Distribution by Scientific Domains

Kinds of Maternal Morbidity

  • serious maternal morbidity

  • Selected Abstracts

    Evaluation of pregnant women with scarred uterus in a low resource setting

    Anjoo Agarwal
    Abstract Aim:, Management of post cesarean pregnancy continues to be a dilemma. The present study was undertaken to evaluate the outcome of such pregnancies in a resource constrained setting so that an appropriate management protocol can be decided. Methods:, An observational study was conducted in the Department Of Obstetrics And Gynecology, King George's Medical University, Lucknow, India. The outcome of all of the women admitted with pregnancy with a previous cesarean section was noted. Results:, A total number of 447 women with a post cesarean pregnancy underwent delivery. These comprised 13.7% of total deliveries over the same period. 124 women (27.7%) had successful vaginal delivery while 323 (72.3%) had a repeat cesarean section. Maternal morbidity and perinatal mortality were both significantly higher in the vaginal delivery group (P = 0.00211 and P = 0.0426, respectively). Conclusions:, Vaginal birth after cesarean (VBAC) is associated with higher maternal morbidity and perinatal mortality. Therefore the decision for VBAC must be taken only after proper consideration and counseling of the couple. [source]

    Development of an Algorithm to Identify Pregnancy Episodes in an Integrated Health Care Delivery System

    Mark C. Hornbrook
    Objective. To develop and validate a software algorithm to detect pregnancy episodes and maternal morbidities using automated data. Data Sources/Study Setting. Automated records from a large integrated health care delivery system (IHDS), 1998,2001. Study Design. Through complex linkages of multiple automated information sources, the algorithm estimated pregnancy histories. We evaluated the algorithm's accuracy by comparing selected elements of the pregnancy history obtained by the algorithm with the same elements manually abstracted from medical records by trained research staff. Data Collection/Extraction Methods. The algorithm searched for potential pregnancy indicators within diagnosis and procedure codes, as well as laboratory tests, pharmacy dispensings, and imaging procedures associated with pregnancy. Principal Findings. Among 32,847 women with potential pregnancy indicators, we identified 24,680 pregnancies occuring to 21,001 women. Percent agreement between the algorithm and medical records review on pregnancy outcome, gestational age, and pregnancy outcome date ranged from 91 percent to 98 percent. The validation results were used to refine the algorithm. Conclusions. This pregnancy episode grouper algorithm takes advantage of databases readily available in IHDS, and has important applications for health system management and clinical care. It can be used in other settings for ongoing surveillance and research on pregnancy outcomes, pregnancy-related morbidities, costs, and care patterns. [source]

    Misoprostol and declining abortion-related morbidity in Santo Domingo, Dominican Republic: a temporal association

    Suellen Miller
    Objective To validate anecdotal reports that abortion-related complications decreased in the Dominican Republic after the introduction of misoprostol into the country. Design Retrospective records reviews and cross-sectional surveys, interviews and focus groups. Setting Family planning clinics, pharmacies, door-to-door canvassing and a tertiary care maternity hospital in Santo Domingo, Dominican Republic. Population Women of reproductive age in Santo Domingo, Dominican Republic. Methods Qualitative and quantitative methods were used. Individual interviews and focus groups of reproductive health professionals, non-governmental organisation leaders and women's group leaders (n= 50) were conducted to discover the role of misoprostol in the Dominican Republic. Local women (n= 157) were surveyed to determine their knowledge of misoprostol as an abortifacient and mystery client visits were made to 80 pharmacies in order to purchase misoprostol without a prescription. Sales data were obtained that documented when misoprostol was introduced to the Dominican Republic pharmacies. Hospital admissions for abortions from the prior eight years were reviewed and hospital emergency room consultation ledgers of 31,190 visits for the period 1994,2001 were reviewed for abortion complications. Main outcome measures Frequencies of maternal morbidities and knowledge of misoprostol. Results Mystery clients purchased misoprostol without a prescription in nearly 64% of pharmacies; staff provided little additional information or counselling. Reliable sales data documented the introduction of misoprostol in 1986. Abortion complications decreased from 11.7% of abortions in 1986 to 1.7% in 2001. The majority of professionals interviewed felt that knowledge of these findings should be made public. Conclusions The data were of too poor quality to validate the verbal reports reliably, but misoprostol appears to have been widely used over a period when abortion-related morbidity fell. It remains plausible that the use of misoprostol contributed to the reduction. [source]

    Outcomes of pregnancies in women with pre-gestational diabetes mellitus and gestational diabetes mellitus; a population-based study in New South Wales, Australia, 1998,2002

    DIABETIC MEDICINE, Issue 6 2008
    A. W. Shand
    Abstract Aim To determine population-based rates and outcomes of pre-gestational diabetes mellitus (pre-GDM) and gestational diabetes mellitus (GDM) in pregnancy. Methods This was a cross-sectional study, using linked population databases, of all women, and their infants, discharged from hospital following birth in New South Wales (NSW) between 1 July 1998 and 31 December 2002. Women with, and infants exposed to pre-GDM or GDM were compared with those without diabetes mellitus for pregnancy characteristics and outcomes. Results Women with a singleton pregnancy (n = 370 703) and their infants were included: 1248 women (0.3%) had pre-GDM and 17 128 (4.5%) had GDM. Of those women with pre-GDM, 57% had Type 1 diabetes, 20% had Type 2 diabetes and for 23% the type of diabetes was unknown. Major maternal morbidity or mortality was more common in women with pre-GDM (7.9%) [odds ratio (OR) 3.2, 95% confidence interval (CI) 2.6, 3.9] and in women with GDM (3.1%) (OR 1.2, 95% CI 1.1, 1.4) when compared with women without diabetes (2.6%). Major infant morbidity or mortality occurred more frequently in infants exposed to pre-GDM compared with no diabetes (13.6% vs. 3.1%) (OR 5.0, 95% CI 4.2, 5.8) and in infants exposed to GDM compared with no diabetes (3.2% vs. 2.3%) (OR 1.4, 95% CI 1.3, 1.5). Conclusions Pre-GDM and GDM continue to be associated with an increased risk of adverse maternal and neonatal outcomes; however, women with GDM have adverse outcomes less frequently. Rates of GDM and pre-GDM appear to be increasing over time. Clinicians should consider the potential for adverse outcomes, and arrange referral to appropriate services. [source]

    The optimal mode of delivery for the haemophilia carrier expecting an affected infant is caesarean delivery

    HAEMOPHILIA, Issue 3 2010
    A. H. JAMES
    Summary., While a majority of affected infants of haemophilia carriers who deliver vaginally do not suffer a head bleed, the outcome of labour cannot be predicted. A planned vaginal delivery puts a woman at risk of an abnormal labour and operative vaginal delivery, both of which predispose to intracranial haemorrhage. Furthermore, vaginal delivery does not eliminate the risk to the haemophilia carrier herself. Overall, maternal morbidity and mortality from planned vaginal delivery are not significantly different from those from planned caesarean delivery. Caesarean delivery is recommended or elected now in conditions other than haemophilia carriage, where the potential benefits are not nearly as great. Additionally, vaginal delivery of the haemophilia carrier poses medical/legal risks if the infant is born with cephalohaematoma or intracranial haemorrhage. Caesarean delivery allows for a planned, controlled delivery. Caesarean delivery reduces the risk of intracranial haemorrhage by an estimated 85% and the risk can be nearly eliminated by performing elective caesarean delivery before labour. Therefore, after a discussion of the maternal and foetal risks with planned vaginal delivery versus planned caesarean delivery, haemophilia carriers should be offered the option of an elective caesarean delivery. [source]

    Role of EG-VEGF in human placentation: Physiological and pathological implications

    Pascale Hoffmann
    Abstract Pre-eclampsia (PE), the major cause of maternal morbidity and mortality, is thought to be caused by shallow invasion of the maternal decidua by extravillous trophoblasts (EVT). Data suggest that a fine balance between the expressions of pro- and anti-invasive factors might regulate EVT invasiveness. Recently, we showed that the expression of the new growth factor endocrine gland-derived vascular endothelial growth factor (EG-VEGF) is high in early pregnancy but falls after 11 weeks, suggesting an essential role for this factor in early pregnancy. Using human villous explants and HTR-8/SVneo, a first trimester extravillous trophoblast cell line, we showed differential expression of EG-VEGF receptors, PKR1 and PKR2, in the placenta and demonstrated that EG-VEGF inhibits EVT migration, invasion and tube-like organisation. EG-VEGF inhibitory effect on invasion was supported by a decrease in matrix metalloproteinase (MMP)-2 and MMP-9 production. Interference with PKR2 expression, using specific siRNAs, reversed the EG-VEGF-induced inhibitory effects. Furthermore, we determined EG-VEGF circulating levels in normal and PE patients. Our results showed that EG-VEGF levels were highest during the first trimester of pregnancy and decreased thereafter to non-pregnant levels. More important, EG-VEGF levels were significantly elevated in PE patients compared with age-matched controls. These findings identify EG-VEGF as a novel paracrine regulator of trophoblast invasion. We speculate that a failure to correctly down-regulate placental expression of EG-VEGF at the end of the first trimester of pregnancy might lead to PE. [source]

    Evaluation of pregnant women with scarred uterus in a low resource setting

    Anjoo Agarwal
    Abstract Aim:, Management of post cesarean pregnancy continues to be a dilemma. The present study was undertaken to evaluate the outcome of such pregnancies in a resource constrained setting so that an appropriate management protocol can be decided. Methods:, An observational study was conducted in the Department Of Obstetrics And Gynecology, King George's Medical University, Lucknow, India. The outcome of all of the women admitted with pregnancy with a previous cesarean section was noted. Results:, A total number of 447 women with a post cesarean pregnancy underwent delivery. These comprised 13.7% of total deliveries over the same period. 124 women (27.7%) had successful vaginal delivery while 323 (72.3%) had a repeat cesarean section. Maternal morbidity and perinatal mortality were both significantly higher in the vaginal delivery group (P = 0.00211 and P = 0.0426, respectively). Conclusions:, Vaginal birth after cesarean (VBAC) is associated with higher maternal morbidity and perinatal mortality. Therefore the decision for VBAC must be taken only after proper consideration and counseling of the couple. [source]

    Morbidity and mortality associated with pre-eclampsia at two tertiary care hospitals in Sri Lanka

    Vajira H. W. Dissanayake
    Abstract Aim:, To report the occurrence of morbidity and mortality associated with carefully phenotyped pre-eclampsia in a sample of nulliparous Sinhalese women with strictly defined disease. Methods:, A phenotyping database of 180 nulliparous women with pre-eclampsia and 180 nulliparous normotensive pregnant women who were recruited for a study into genetics of pre-eclampsia was analyzed. Results:, Women who developed pre-eclampsia had significantly higher systolic blood pressure (SBP; P = 0.002) and diastolic blood pressure (DBP; P = 0.002) at booking (at approximately 13 weeks of gestation). 38.3%, 28.3% and 33.3% of women delivered at <34 weeks, at 34,36 weeks, and at term, respectively. 78% required a cesarean section. Complications included SBP , 160 mmHg (75.5%); DBP , 110 mmHg (83.8%); proteinuria ,3 + (150 mg/dL) in the urine protein heat coagulation test (87%); renal failure requiring dialysis (2%); platelet counts <100 109/L (13%); ,70 U/L in aspartate and/or alanine aminotransaminase (15%); placental abruption (4%); eclampsia (9%); and one maternal death. Maternal complications indicative of severe disease, apart from the incidence of SBP , 160 mmHg and DBP , 110 mmHg, were not significantly different in early and late-onset pre-eclampsia; fetal outcome was better with late-onset disease. 48% of babies were small for gestational age. Only 80 of 135 babies of women with pre-eclampsia whose condition could be confirmed at 6 weeks post-partum were alive. Conclusions:, Pre-eclampsia in Sinhalese women is associated with severe maternal morbidity and fetal morbidity and mortality, suggesting that modification of the Western diagnostic criteria and/or guidelines for medical care may be necessary. There is an urgent need to improve neonatal intensive care services in Sri Lanka. [source]

    The gestational timing of pregnancy loss: Adaptive strategy?,

    Donna Day Baird
    This commentary links early pregnancy milestones (rescue of the corpus luteum, the luteal-placental shift, and blocking of the spiral arteries) with the pattern of gestation-specific pregnancy loss in humans. The objective is to describe the pattern and present an adaptive hypothesis: that high first trimester pregnancy loss results from selection to reduce the risk of maternal morbidity and mortality associated with human delivery. Specific questions within the broad framework of this hypothesis can be addressed with research in comparative physiology and endocrinology. Am. J. Hum. Biol., 2009. Published 2009 Wiley-Liss, Inc. [source]

    Altered levels of insulin-like growth factor binding protein proteases in preeclampsia and intrauterine growth restriction

    PRENATAL DIAGNOSIS, Issue 9 2010
    Julian K. Christians
    Abstract Intrauterine growth restriction (IUGR) and preeclampsia (PE) are leading causes of perinatal and maternal morbidity and mortality. Many studies have found association between low levels of insulin-like growth factor binding protein (IGFBP) proteases in the first trimester maternal circulation and the risk of subsequent development of PE and/or IUGR. These results are generally interpreted to reflect decreased production of the proteases by the placenta, leading to reduced proteolysis of IGFBPs and lower free levels of insulin-like growth factor (IGF), resulting in diminished feto-placental development. However, the association between low circulating levels of placental proteins early in pregnancy and the subsequent development of IUGR and/or PE could be due to low exchange in the placenta and not due to reduced production. In contrast, late in pregnancy, the circulating levels of these proteins and their expression in the placenta are often elevated in PE, which may reflect upregulation to compensate for abnormal placental development, that is an adaptive mechanism to increase IGFBP proteolysis, increase local IGF levels and promote feto-placental growth. Further research into the biological mechanisms underlying these associations will aid the identification of high-risk pregnancies and the development of therapeutic targets for diseases for which there are presently no preventative measures. Copyright 2010 John Wiley & Sons, Ltd. [source]

    MFM/geneticist view on prenatal management of twins,

    Barbara M. O'Brien
    Abstract Twin pregnancies are associated with an increase in both fetal and maternal morbidity and mortality. Health care supervision is complex, increasingly requiring care from maternal-fetal medicine specialists. This review discusses optimal twin prenatal management, which includes recognizing increased twin pregnancy risks specific to twin-types; counseling families regarding fetal complications, ranging from prematurity to cerebral palsy; screening for aneuploidy and open neural tube defects; specific twin guidelines for diagnostic testing, including chorionic villus sampling and amniocentesis; and monitoring for maternal complications. 2009 Wiley-Liss, Inc. [source]

    Evidence for Superantigen Involvement in Preeclampsia

    PROBLEM: Preeclampsia is the leading cause of maternal morbidity and premature fetal delivery in the United States, most likely involving the immune system in disease genesis. In this report, we tested the hypothesis that a superantigen phenomenon is an important factor in the pathogenesis of the disease. METHOD OF STUDY: A semi-quantitative polymerase chain reaction (PCR) was used to assess T-cell receptor (TCR) , chain variable (V,) regions as an indicator of T-cell expansion in both peripheral blood and basal plate of preeclamptic patients. All the subjects were also molecularly typed to identify their HLA-class II alleles. RESULTS: In peripheral blood of the majority of the patients, there was a high abundance of the V,4 gene family, which was not observed in the control group. Polyclonality of this V, gene family was confirmed by analysis of the V, chain and the complementary determining region 3 (CDR3). The majority of patients carried the Human Leukocyte Antigens (HLA)-DRB1*13 allele. CONCLUSION: We present evidence for the existence of a superantigen-like effect in at least a subset of patients with preeclampsia. [source]

    Rapid sequence spinal anaesthesia for category-1 urgency caesarean section: a case series

    ANAESTHESIA, Issue 7 2010
    S. M. Kinsella
    Summary General anaesthesia is the fastest method for anaesthetising a category-1 caesarean section but is associated with increased maternal morbidity and mortality. We describe the ,rapid sequence spinal' to minimise anaesthetic time. This consists of a no-touch spinal technique, consideration of omission of the spinal opioid, limiting spinal attempts, allowing the start of surgery before full establishment of the spinal block, and being prepared for conversion to general anaesthesia if there are delays or problems. We present a case series of 25 rapid sequence spinal anaesthetics for category-1 caesarean section. The mean (SD [range]) decision-delivery interval was 23 (6 [14,41]) min. After excluding cases where there was an identified delay, the median (IQR [range]) time to prepare and perform the spinal was 2 (2,3 [1,7]) min, and time to develop a ,satisfactory' block was 4 (3,5 [2,7]) min. The total time to induce spinal anaesthesia was 8 (7,8 [6,8]) min. There were three pre-operative conversions to general anaesthesia and three women had pain during surgery that did not require treatment. Our data indicate that one might expect to establish anaesthesia in 6,8 min using a rapid sequence spinal. Careful case selection is crucial. While rapid anaesthesia is important, the reduction of the decision-delivery interval also requires attention to other stages in the pre-operative process. [source]

    Original Article: Audit of severe acute maternal morbidity describing reasons for transfer and potential preventability of admissions to ICU

    Beverley A. LAWTON
    Background:, Maternal mortality is a rare event in the developed world. Assessment of severe acute maternal morbidity (SAMM) is therefore an appropriate measure of the quality of maternity care. Aims:, The aim of the study was to conduct a retrospective audit of SAMM cases (pregnant women admitted to a New Zealand Intensive Care Unit) to describe clinical, socio-demographic characteristics, pregnancy outcomes and preventability. Methods:, Severe acute maternal morbidity cases were reviewed by a multidisciplinary panel to determine reasons for admission to ICU, to classify organ-system dysfunction and to determine whether the SAMM case was preventable or not. Inclusion criteria were: admission to ICU between 2005 and 2007 during pregnancy or within 42 days of delivery. Results:, Twenty-nine SAMM cases were reviewed, of which 10 (35%) were deemed preventable. The most common reasons for transfer to ICU were: the need for invasive vascular monitoring, hypotension and disseminated intravascular coagulation. The most frequent types of preventable events were: inadequate diagnosis/recognition of high-risk status, inappropriate treatment, communication problems and inadequate documentation. All five SAMM cases of septicaemia were deemed preventable. Of the ten preventable cases, three were Maori (50% of the Maori in total audit), four were Pacific (67% of the Pacific in total audit) and three were women of ,other' ethnicities (17.6%, 3 of 17 in the audit). Conclusions:, An audit of SAMM cases describing reasons for transfer to ICU and preventability is feasible. We recommend that a prospective national SAMM audit process be introduced in New Zealand as a quality of care measure. [source]

    Conservative management of clinically diagnosed placenta accreta following vaginal delivery

    Michael J. BENNETT
    Placenta accreta can result in substantial maternal morbidity and mortality. Conservative management of placenta accreta following vaginal delivery is discussed in this case series. These cases demonstrate serial ultrasonographic resorption of placenta accreta left in situ following vaginal delivery with minimal blood product requirements and preservation of fertility. [source]

    Twin deliveries and place of birth in NSW 2001,2005

    Charles S. ALGERT
    Background:, Twin pregnancies have an elevated risk of adverse outcomes, particularly preterm twins. Aims:, Describe the distribution of twin deliveries by hospital level, the associated perinatal and maternal morbidity, and determine predictors of perinatal morbidity and urgent transfer to a neonatal intensive care unit. Methods:, Longitudinally linked New South Wales delivery and hospital records for the years 2001,2005 were used to identify perinatal and maternal morbidity/mortality in twin pregnancies. Regression analysis was used to examine predictive factors, including birth hospital volume. Results:, At , 32 weeks, 88.1% of twins were delivered in tertiary referral hospitals. By 34,35 weeks, only 39.7% of twins were delivered in tertiary units. Gestational age was the primary predictor of perinatal morbidity/mortality. Perinatal morbidity/mortality and maternal morbidity were lowest for deliveries at 38 weeks. There was no evidence that planned caesarean section at , 38 weeks was protective against perinatal morbidity/mortality. There was an increased risk of perinatal morbidity/mortality (odds ratio (OR) = 2.22) for twins delivered at 33,35 weeks gestation at hospitals with < 500 deliveries per annum, and an increased risk of urgent neonatal transfer (OR = 2.06). Twin pairs for whom there was a , 20% discordance in birthweight had an increased risk of morbidity/mortality at 36,38 weeks (OR = 1.79). Conclusions:, Both infant and maternal morbidity increase from 39 weeks gestation. Delivery of twins before 36 weeks at smaller hospitals (< 500 deliveries per annum) should be avoided. A twin pregnancy where there is a , 20% difference in estimated fetal weights should be considered for referral to a tertiary obstetric unit. [source]

    Is routine cervical dilatation necessary during elective caesarean section?

    A randomised controlled trial
    Objective: The purpose of this prospective randomised study was to determine the effect of routine cervical dilatation during elective caesarean section on maternal morbidity. Methods: Participants with indication for elective caesarean section were randomly allocated to two groups. Group A (n = 200) women with intraoperative cervical dilatation; group B (n = 200) women with no intraoperative cervical dilatation. Results: No demographic differences were observed between groups. There was no significant difference between groups in infectious morbidity (P = 0.87) (relative risk (RR) 1.11, 95% confidence interval (CI) 0.58,2.11), endometritis (P = 0.72) (RR 1.68, 95% CI 0.39,7.14), febrile morbidity (P = 0.66) (RR 1.21, 95% CI 0.51,2.87), wound infection (P = 0.82) (RR 1.11, 95% CI 0.44,2.81), endometritis (P = 0.72) (RR 1.68, 95% CI 0.39,7.14) or urinary tract infection (P = 1.00) (RR 1.00, 95% CI 0.28,3.50), and estimated blood loss (P = 0.2). However, group A had longer operative times compared with the group B (P = 0.01). Conclusion: Intraoperative digital cervical dilatation during elective caesarean section did not reduce blood loss and postoperative infectious morbidity. The routine digital cervical dilatation during elective caesarean section is not recommended. [source]

    Outcomes Associated with Planned Home and Planned Hospital Births in Low-Risk Women Attended by Midwives in Ontario, Canada, 2003,2006: A Retrospective Cohort Study

    BIRTH, Issue 3 2009
    Eileen K. Hutton PhD
    ABSTRACT: Background: Midwives in Ontario, Canada, provide care in the home and hospital and are required to submit data for all births to the Ontario Ministry of Health database. The purpose of this study was to compare maternal and perinatal/neonatal mortality and morbidity and intrapartum intervention rates for women attended by Ontario midwives who planned a home birth compared with similar low-risk women who planned a hospital birth between 2003 and 2006.Methods: The database provided outcomes for all women planning a home birth at the onset of labor (n = 6,692) and for a cohort, stratified by parity, of similar low-risk women planning a hospital birth.Results: The rate of perinatal and neonatal mortality was very low (1/1,000) for both groups, and no difference was shown between groups in perinatal and neonatal mortality or serious morbidity (2.4% vs 2.8%; relative risk [RR], 95% confidence intervals [CI]: 0.84 [0.68,1.03]). No maternal deaths were reported. All measures of serious maternal morbidity were lower in the planned home birth group as were rates for all interventions including cesarean section (5.2% vs 8.1%; RR [95% CI]: 0.64 [0.56, 0.73]). Nulliparas were less likely to deliver at home, and had higher rates of ambulance transport from home to hospital than multiparas planning home birth and had rates of intervention and outcomes similar to, or lower than, nulliparas planning hospital births.Conclusions: Midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births. [source]

    Evidence-Based Strategies for Reducing Cesarean Section Rates: A Meta-Analysis

    BIRTH, Issue 1 2007
    Nils Chaillet PhD
    ABSTRACT: Background: Canada's cesarean section rate reached an all-time high of 22.5 percent of in-hospital deliveries in 2002 and was associated with potential maternal and neonatal complications. Clinical practice guidelines represent an appropriate mean for reducing cesarean section rates. The challenge now lies in implementing these guidelines. Objectives of this meta-analysis were to assess the effectiveness of interventions for reducing the cesarean section rate and to assess the impact of this reduction on maternal and perinatal mortality and morbidity. Methods: The Cochrane Library, EMBASE, and MEDLINE were consulted from January 1990 to June 2005. Additional studies were identified by screening reference lists from identified studies and expert suggestions. Studies involving rigorous evaluation of a strategy for reducing overall cesarean section rates were identified. Randomized controlled trials, controlled before-and-after studies, and interrupted time series studies were evaluated according to Effective Practice and Organisation of Care Group criteria. Results: Among the 10 included studies, a significant reduction of cesarean section rate was found by random meta-analysis (pooled RR = 0.81 [0.75, 0.87]). No evidence of publication bias was identified. Audit and feedback (pooled RR = 0.87 [0.81, 0.93]), quality improvement (pooled RR = 0.74 [0.70, 0.77]), and multifaceted strategies (pooled RR=0.73 [0.68, 0.79]) were effective for reducing the cesarean section rate. However, quality improvement based on active management of labor showed mixed effects. Design of studies showed a higher effect for noncontrolled studies than for controlled studies (pooled RR = 0.76 [0.72, 0.81] vs 0.92 [0.88, 0.96]). Studies including an identification of barriers to change were more effective than other interventions for reducing the cesarean section rate (pooled RR = 0.74 [0.71, 0.78] vs 0.88 [0.82, 0.94]). Among included studies, no significant differences were found for perinatal and neonatal mortality and perinatal and maternal morbidity with respect to the mode of delivery. Only 1 study showed a significant reduction of neonatal and perinatal mortality (p < 0.001). Conclusions: The cesarean section rate can be safely reduced by interventions that involve health workers in analyzing and modifying their practice. Our results suggest that multifaceted strategies, based on audit and detailed feedback, are advised to improve clinical practice and effectively reduce cesarean section rates. Moreover, these findings support the assumption that identification of barriers to change is a major key to success. (BIRTH 34:1 March 2007) [source]

    Maternal mortality and serious maternal morbidity in Jehovah's witnesses in the Netherlands

    ME Van Wolfswinkel
    Objective, To determine the risk of maternal mortality and serious maternal morbidity because of major obstetric haemorrhage in Jehovah's witnesses in the Netherlands. Design, A retrospective study of case notes. Setting, All tertiary care centres, general teaching hospitals and other general hospitals in the Netherlands. Sample, All cases of maternal mortality in the Netherlands between 1983 and 2006 and all cases of serious maternal morbidity in the Netherlands between 2004 and 2006. Methods, Study of case notes using two different nationwide enquiries over two different time periods. Main outcome measures, Maternal mortality ratio (MMR) and risk of serious maternal mortality. Results, The MMR for Jehovah's witnesses was 68 per 100 000 live births. We found a risk of 14 per 1000 for Jehovah's witnesses to experience serious maternal morbidity because of obstetric haemorrhage while the risk for the total pregnant population was 4.5 per 1000. Conclusions, Women who are Jehovah's witnesses are at a six times increased risk for maternal death, at a 130 times increased risk for maternal death because of major obstetric haemorrhage and at a 3.1 times increased risk for serious maternal morbidity because of obstetric haemorrhage, compared to the general Dutch population. [source]

    Tocolysis for repeat external cephalic version in breech presentation at term: a randomised, double-blinded, placebo-controlled trial

    Lawrence Impey
    Background External cephalic version (ECV) reduces the incidence of breech presentation at term and caesarean section for non-cephalic births. Tocolytics may improve success rates, but are time consuming, may cause side effects and have not been proven to alter caesarean section rates. The aim of this trial was to determine whether tocolysis should be used if ECV is being re-attempted after a failed attempt. Objective To determine whether tocolysis should be used if ECV is being re-attempted after a failed attempt. Design Randomised, double-blinded, placebo-controlled trial. Setting UK teaching hospital. Population One hundred and twenty-four women with a breech presentation at term who had undergone an unsuccessful attempt at ECV. Methods Relative risks with 95% confidence intervals for categorical variables and a t test for continuous variables. Analysis was by intention to treat. Main outcome measures Incidence of cephalic presentation at delivery. Secondary outcomes were caesarean section and measures of neonatal and maternal morbidity. Results The use of tocolysis for a repeat attempt at ECV significantly increases the incidence of cephalic presentation at delivery (RR 3.21; 95% CI 1.23,8.39) and reduces the incidence of caesarean section (RR 0.33; 95% CI 0.14,0.80). The effects were most marked in multiparous women (RR for cephalic presentation at delivery 9.38; 95% CI 1.64,53.62). Maternal and neonatal morbidity remain unchanged. Conclusions The use of tocolysis increases the success rate of repeat ECV and reduces the incidence of caesarean section. A policy of only using tocolysis where an initial attempt has failed leads to a relatively high success rate with minimum usage of tocolysis. [source]

    Incidence of severe pre-eclampsia, postpartum haemorrhage and sepsis as a surrogate marker for severe maternal morbidity in a European population-based study: the MOMS-B survey

    Wei-Hong Zhang
    Objective To describe the incidence of three conditions of acute severe maternal morbidity in selected regions in nine European countries. Design A population-based questionnaire survey. Setting Eleven regions in nine countries of Europe. Population All the pregnant women in each region who had delivered during the period covered by the study. Methods Standard definitions of three severe obstetric conditions, pre-eclampsia, postpartum haemorrhage and sepsis were established by a steering committee. A common questionnaire was used in each participating country. The incidence of the three obstetric conditions and characteristics of the study women were compared. Main outcome measures Incidence of three severe obstetric conditions: pre-eclampsia, postpartum haemorrhage and sepsis. Results The study identified 1734 women with at least one of the three conditions, with 847 experiencing severe haemorrhage, 793 experiencing severe pre-eclampsia and 142 experiencing severe sepsis. There were wide variations in incidence of three conditions combined, ranging from 14.7 per thousand deliveries in Brussels, Belgium to 6.0 per thousand deliveries in Upper Austria. Conclusions This study sets a simple and straightforward approach to the definition of three severe obstetric conditions and allows population-based comparisons between developed countries in Europe, even though difficulties may have been present with applying the definition across countries. The reported incidence of these severe obstetric conditions in general and severe haemorrhage varied significantly between countries. Overall, severe haemorrhage in particular was the most common of the three conditions, followed closely by severe pre-eclampsia. [source]

    Pregnancy outcome in severe placental abruption

    Salma Imran Kayani
    Objective To determine the relationship between decision to delivery interval and perinatal outcome in severe placental abruption. Design A case,control study. Setting Large inner city teaching hospital. Methods Retrospective case note review of pregnancies terminated following severe placental aburption and fetal bradycardia. One year paediatric follow up by case note review or postal questionnaire. The differences in outcome (death or cerebral palsy) were examined using non-parametric and univariate analysis for the following time periods , times from onset of symptoms to delivery, onset of symptoms to admission, admission to delivery, onset bradycardia to delivery and decision to delivery interval. Main outcome measures Prenatal death or survival with cerebral palsy. Results Thirty-three women with singleton pregnancies over 28 weeks of gestation, admitted with clinically overt placental abruption, where delivery was effected for fetal bradycardia. Eleven of the pregnancies had a poor outcome (cases), eight infants died and three surviving infants have cerebral palsy. Twenty-two pregnancies had a good outcome (controls): survival with no developmental delay. No statistically significant relationship was found between maternal age, parity, gestation, or birthweight and a poor outcome. A statistically significant relationship between time from decision to delivery was identified (P= 0.02, Mann,Whitney U test). The results of a univariate logistic regression for this variable suggest that the odds ratio of a poor outcome for delivery at 20 minutes compared with 30 minutes is 0.44 (95% CI 0.22,0.86). Fifty-five percent of infants were delivered within 20 minutes of the decision to deliver. Serious maternal morbidity was rare. Conclusion In this small study of severe placental abruption complicated by fetal bradycardia, a decision to delivery interval of 20 minutes or less was associated with substantially reduced neonatal morbidity and mortality. [source]

    Role of proteinuria in defining pre-eclampsia: Clinical outcomes for women and babies

    Charlene E Thornton
    Summary 1.,The presence of proteinuria is not essential to the diagnosis of pre-eclampsia under many diagnostic consensus statements. The aim of the present study was to assess maternal and perinatal outcomes after proteinuric pre-eclampsia compared with other non-proteinuric disease presentations. 2.,An individual patient data review (n = 670) was undertaken for 2003,2006 at a tertiary referral centre in Sydney (NSW, Australia). Women were diagnosed in accordance with the Australasian Society for the Study of Hypertension in Pregnancy Consensus Statement. Data were analysed with the Chi-squared test, t -tests and non-parametric tests. Statistical significance was set at P < 0.05. 3.,The proteinuric cohort had higher systolic and diastolic blood pressure recordings than the non-proteinuric cohort (160/102 and 149/94 mmHg, respectively; P < 0.001), and were also administered magnesium sulphate more frequently (44 vs 22%, respectively; P < 0.001), delivered at earlier gestation (37 vs 38 weeks, respectively; P < 0.001), required operative delivery more frequently (63 vs 48%, respectively; P < 0.001) and received more antihypertensive medications during the antenatal period (72 vs 57%, respectively; P < 0.001). Acute renal failure and acute pulmonary oedema were rare. Four cases of eclampsia all occurred in non-proteinuric women. The perinatal mortality rate was lower for the offspring of women with proteinuric pre-eclampsia compared with offspring of non-proteinuric women (13/1000 and 31/1000, respectively; P = 0.006). 4.,The results of the present study indicate that the presence of proteinuria denotes a group of women who have higher antenatal blood pressure, who deliver at earlier gestation and require operative delivery more commonly, although it is not an indicator of other markers of maternal morbidity or perinatal mortality. [source]