Peripartum hysterectomy due to severe postpartum hemorrhage: A hospital-based study.

INTRODUCTION: A peripartum hysterectomy is typically performed as a lifesaving procedure in obstetrics to manage severe postpartum hemorrhage. Severe hemorrhages that lead to peripartum hysterectomies are mainly caused by uterine atony and placenta accreta spectrum disorders. In this study, we aimed to estimate the incidence, risk factors, causes and management of severe postpartum hemorrhage resulting in peripartum hysterectomies, and to describe the complications of the hysterectomies. MATERIAL AND METHODS: Eligible women had given birth at gestational week 23+0 or later and had a postpartum hemorrhage ≥1500 mL or a blood transfusion, due to postpartum hemorrhage, at Oslo University Hospital, Norway, between 2008 and 2017. Among the eligible women, this study included those who underwent a hysterectomy within the first 42 days after delivery. The Norwegian Medical Birth Registry provided the reference group. We used Poisson regression to estimate adjusted incidence rate ratios with 95% confidence intervals to identify clinical factors associated with peripartum hysterectomy. RESULTS: The incidence of hysterectomies with severe postpartum hemorrhage was 0.44/1000 deliveries (42/96313). Among the women with severe postpartum hemorrhage, 1.6% ended up with a hysterectomy (42/2621). Maternal age ≥40, previous cesarean section, multiple pregnancy and placenta previa were associated with a significantly higher risk of hysterectomy. Placenta accreta spectrum disorders were the most frequent cause of hemorrhage that resulted in a hysterectomy (52%, 22/42) and contributed to most of the complications following the hysterectomy (11/15 women with complications). CONCLUSIONS: The rate of peripartum hysterectomies at Oslo University Hospital was low, but was higher than previously reported from Norway. Risk factors included high maternal age, previous cesarean section, multiple pregnancy and placenta previa, well known risk factors for placenta accreta spectrum disorders and severe postpartum hemorrhage. Placenta accreta spectrum disorders were the largest contributor to hysterectomies and complications.

The impact of cardiovascular diseases on maternal deaths in the Nordic countries.

INTRODUCTION: Cardiovascular diseases have become increasingly important as a cause of maternal death in the Nordic countries. This is likely to be associated with a rising incidence of pregnant women with congenital and acquired cardiac diseases. Through audits, we aim to prevent future maternal deaths by identifying causes of death and suboptimal factors in the clinical management. MATERIAL AND METHODS: Maternal deaths in the Nordic countries from 2005 to 2017 were identified through linked registers. The national audit groups performed case assessments based on hospital records, classified the cause of death, and evaluated the standards of clinical care provided. Key messages were prepared to improve treatment. RESULTS: We identified 227 maternal deaths, giving a maternal mortality rate of 5.98 deaths per 100 000 live births. The most common cause of death was cardiovascular disease (n = 36 deaths). Aortic dissection/rupture, myocardial disease, and ischemic heart disease were the most common diagnoses. In nearly 60% of the cases, the disease was not recognized before death. In more than half of the deaths, substandard care was identified (59%). In 11 deaths (31%), improvements to care that may have made a difference to the outcome were identified. CONCLUSIONS: Between 2005 and 2017, cardiovascular diseases were the most common causes of maternal deaths in the Nordic countries. There appears to be a clear potential for a further reduction in these maternal deaths. Increased awareness of cardiac symptoms in pregnant women seems warranted.

COVID-19 in pregnancy-characteristics and outcomes of pregnant women admitted to hospital because of SARS-CoV-2 infection in the Nordic countries.

INTRODUCTION: Population-based studies about the consequences of SARS-CoV-2 infection (COVID-19) in pregnancy are few and have limited generalizability to the Nordic population and healthcare systems. MATERIAL AND METHODS: This study examines pregnant women with COVID-19 in the five Nordic countries. Pregnant women were included if they were admitted to hospital between 1 March and 30 June 2020 and had a positive SARS-CoV-2 PCR test ≤14 days prior to admission. Cause of admission was classified as obstetric or COVID-19-related. RESULTS: In the study areas, 214 pregnant women with a positive test were admitted to hospital, of which 56 women required hospital care due to COVID-19. The risk of admission due to COVID-19 was 0.4/1000 deliveries in Denmark, Finland and Norway, and 3.8/1000 deliveries in the Swedish regions. Women hospitalized because of COVID-19 were more frequently obese (p < 0.001) and had a migrant background (p < 0.001) compared with the total population of women who delivered in 2018. Twelve women (21.4%) needed intensive care. Among the 56 women admitted due to COVID-19, 48 women delivered 51 infants. Preterm delivery (n = 12, 25%, p < 0.001) and cesarean delivery (n = 21, 43.8%, p < 0.001) were more frequent in women with COVID-19 compared with women who delivered in 2018. No maternal deaths, stillbirths or neonatal deaths were reported. CONCLUSIONS: The risk of admission due to COVID-19 disease in pregnancy was low in the Nordic countries. A fifth of the women required intensive care and we observed higher rates of preterm and cesarean deliveries. National public health policies appear to have had an impact on the risk of admission due to severe COVID-19 disease in pregnancy. Nordic collaboration is important in collecting robust data and assessing rare outcomes.

Maternal deaths from hypertensive disorders: lessons learnt.

INTRODUCTION: Hypertensive disorders of pregnancy have been the most frequent cause of maternal death in Norway since 1996 and are strongly associated with substandard care. In the UK, the number of maternal deaths due to hypertensive disorders has decreased drastically due to the implementation of updated guidelines, indicating a potential for reducing the number of deaths in other countries as well. Through audits of maternal deaths, we aim to prevent future deaths from hypertensive disorders in pregnancy by identifying suboptimal factors in treatment. MATERIAL AND METHODS: Maternal deaths in Norway from 1996 to 2014 were identified through linked registries. The Norwegian Maternal Mortality Audit Group performed all case assessments included in this study, classified the cause of death, evaluated the treatment, and identified suboptimal factors to care in each case. Emphasis was placed on antihypertensive treatment, timing of delivery, stabilization before delivery, and quality of care. Learning points were prepared to improve the treatment of hypertensive disorders of pregnancy. RESULTS: We identified 74 maternal deaths. The maternal mortality rate was 6.5 deaths per 100 000 live births. The most common cause of death was hypertensive disorders (n = 16 deaths). In 14 of these deaths (87%), the audit group concluded that improvements to care could have made a difference to the outcome. CONCLUSIONS: In 1996-2014, hypertensive disorders were the most common cause of maternal death in Norway. Our study indicates that such deaths can be prevented by improvements in antihypertensive treatment and the timing of delivery.

Maternal deaths in the Nordic countries.

INTRODUCTION: Despite the seriousness of the event, maternal deaths are substantially underreported. There is often a missed opportunity to learn from such tragedies. The aim of the study was to identify maternal deaths in the five Nordic countries, to classify causes of death based on internationally acknowledged criteria, and to identify areas that would benefit from further teaching, training or research to possibly reduce the number of maternal deaths. MATERIAL AND METHODS: We present data for the years 2005-2013. National audit groups collected data by linkage of registers and direct reporting from hospitals. Each case was then assessed to determine the cause of death, and level of care provided. Potential improvements to care were evaluated. RESULTS: We registered 168 maternal deaths, 90 direct and 78 indirect cases. The maternal mortality ratio was 7.2/100 000 live births ranging from 6.8 to 8.1 between the countries. Cardiac disease (n = 29) was the most frequent cause of death, followed by preeclampsia (n = 24), thromboembolism (n = 20) and suicide (n = 20). Improvements to care which could potentially have made a difference to the outcome were identified in one-third of the deaths, i.e. in as many as 60% of preeclamptic, 45% of thromboembolic, and 32% of the deaths from cardiac disease. CONCLUSION: Direct deaths exceeded indirect maternal deaths in the Nordic countries. To reduce maternal deaths, increased efforts to better implement existing clinical guidelines seem warranted, particularly for preeclampsia, thromboembolism and cardiac disease. More knowledge is also needed about what contributes to suicidal maternal deaths.

Maternal mortality in eight European countries with enhanced surveillance systems: descriptive population based study.

OBJECTIVE: To compare maternal mortality in eight countries with enhanced surveillance systems. DESIGN: Descriptive multicountry population based study. SETTING: Eight countries with permanent surveillance systems using enhanced methods to identify, document, and review maternal deaths. The most recent available aggregated maternal mortality data were collected for three year periods for France, Italy, and the UK and for five year periods for Denmark, Finland, the Netherlands, Norway, and Slovakia. POPULATION: 297 835 live births in Denmark (2013-17), 301 169 in Finland (2008-12), 2 435 583 in France (2013-15), 1 281 986 in Italy (2013-15), 856 572 in the Netherlands (2014-18), 292 315 in Norway (2014-18), 283 930 in Slovakia (2014-18), and 2 261 090 in the UK (2016-18). OUTCOME MEASURES: Maternal mortality ratios from enhanced systems were calculated and compared with those obtained from each country's office of vital statistics. Age specific maternal mortality ratios; maternal mortality ratios according to women's origin, citizenship, or ethnicity; and cause specific maternal mortality ratios were also calculated. RESULTS: Methods for identifying and classifying maternal deaths up to 42 days were very similar across countries (except for the Netherlands). Maternal mortality ratios up to 42 days after end of pregnancy varied by a multiplicative factor of four from 2.7 and 3.4 per 100 000 live births in Norway and Denmark to 9.6 in the UK and 10.9 in Slovakia. Vital statistics offices underestimated maternal mortality by 36% or more everywhere but Denmark. Age specific maternal mortality ratios were higher for the youngest and oldest mothers (pooled relative risk 2.17 (95% confidence interval 1.38 to 3.34) for women aged <20 years, 2.10 (1.54 to 2.86) for those aged 35-39, and 3.95 (3.01 to 5.19) for those aged ≥40, compared with women aged 20-29 years). Except in Norway, maternal mortality ratios were ≥50% higher in women born abroad or of minoritised ethnicity, defined variously in different countries. Cardiovascular diseases and suicides were leading causes of maternal deaths in each country. Some other conditions were also major contributors to maternal mortality in only one or two countries: venous thromboembolism in the UK and the Netherlands, hypertensive disorders in the Netherlands, amniotic fluid embolism in France, haemorrhage in Italy, and stroke in Slovakia. Only two countries, France and the UK, had enhanced methods for studying late maternal deaths, those occurring between 43 and 365 days after the end of pregnancy. CONCLUSIONS: Variations in maternal mortality ratios exist between high income European countries with enhanced surveillance systems. In-depth analyses of differences in the quality of care and health system performance at national levels are needed to reduce maternal mortality further by learning from best practices and each other. Cardiovascular diseases and mental health in women during and after pregnancy must be prioritised in all countries.