Effect of delayed interval delivery of remaining fetus(es) in multiple pregnancies on survival: a systematic review and meta-analysis.

BACKGROUND: The management of the pregnancy after delivery of the first fetus during a second-trimester miscarriage or very early preterm birth has not been well defined. OBJECTIVE: The objective of the study was to evaluate whether delayed interval delivery of the remaining fetus(es) in twins/triplets is associated with improved survival, when compared with immediate delivery, after miscarriage or very preterm birth of the first fetus in multiple pregnancy. DATA SOURCES: PubMed, MEDLINE, and Cochrane Library were systematically searched through January 2019. STUDY ELIGIBILITY CRITERIA (STUDY DESIGN, POPULATIONS, AND INTERVENTIONS): The following eligibility criteria applied: full-text original article; included at least 5 cases of delayed interval delivery for remaining fetus(es); and reported the survival rate of the first-born and the remaining fetus(es). STUDY APPRAISAL AND SYNTHESIS METHODS: K.W.C. and W.W. searched, screened, and reviewed the articles. The quality of the studies was assessed according to the Strengthening the Reporting of Observational studies in Epidemiology checklist. If possible, data were stratified for assigned chorionicity. Effect sizes were pooled through a meta-analysis. RESULTS: A total of 2295 published article and abstracts were identified. Only 16 studies met inclusion criteria. Meta-analysis of 492 pregnancies (432 twins [88%], 56 triplets [11%], 3 quadruplets and 1 quintuplets) showed that delayed interval delivery significantly improved the perinatal survival of remaining fetus(es) compared with the first born (odds ratio, 5.22, 95% confidence interval, 2.95-9.25, I2 = 53%), before 20+0 weeks (odds ratio, 6.32, 95% confidence interval, 1.99-20.13, I2 = 0%), between 20+0 and 23+6 weeks (odds ratio, 3.31, 95% confidence interval, 1.95-5.63, I2 = 0%), and after 24+0 weeks (odds ratio, 1.92, 95% confidence interval, 1.21-3.05, I2 = 0%), in dichorionic twin pregnancy (odds ratio, 14.89, 95% confidence interval, 6.19-35.84, I2 = 0%), and unselected triplet pregnancy (odds ratio, 2.33, 95% confidence interval, 1.02-5.32, I2 = 0%. ). Among the survivors, there were no significant differences in the short-term and long-term neonatal morbidities between the first-born and the remaining fetus(es). Serious maternal morbidity was reported in 39% of pregnancy after delayed interval delivery (71 of 183). In addition, 2 cases were managed by postpartum hysterectomy and 1 reported postoperative uterovaginal fistula. There were no recorded cases of maternal mortality. CONCLUSION: Delayed interval delivery when a fetus has delivered in a multiple pregnancy is an effective management option to increase the survival rate of the remaining fetus(es). About 39% of women may experience morbidity following this management option.

Maternal near-miss and death associated with abortive pregnancy outcome: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey.

OBJECTIVE: To investigate the prevalence of life-threatening complications related to pregnancies with abortive outcome and the associated health service events and performance in Nigerian public tertiary hospitals. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy-related complications. METHODS: All cases of severe maternal outcomes (SMO: maternal near-miss or death) due to abortive pregnancy complications (defined as spontaneous or induced abortion, and ectopic pregnancy) were prospectively identified over 1 year using uniform identification criteria. MAIN OUTCOME MEASURES: Prevalence of SMO, mortality index (% maternal death/SMO), case fatality rate, time until death after admission, and health service performance. RESULTS: Of 5779 women admitted with abortive pregnancy complications, 444 (7.9%) experienced an SMO: 366 maternal near-misses and 78 maternal deaths. Intra-hospital maternal mortality ratio from complicated abortive pregnancy outcome was 85/100 000 live births. Case fatality rate was worst for abortion-related infections (19.1%). A quarter of maternal deaths occurred on the same day of admission; however, the peak time of occurrence of death was 3-7 days of admission. Women experiencing cardiovascular, renal or coagulation organ dysfunction were less likely to survive. Higher level of maternal education and closer residence to a health facility improved chance of maternal survival. CONCLUSIONS: Abortive outcome remains a major contributor to SMO in Nigeria. Although early hospital presentation by women is critical to surviving abortive pregnancy complications, improved, appropriate, and timely management is essential to enhance maternal survival. TWEETABLE ABSTRACT: 78 maternal deaths and 366 near-misses occurred from abortions and ectopic pregnancies in 42 Nigerian referral hospitals in 1 year.

Pregnancy-related and maternal deaths in Hamburg, Germany: an autopsy study from 1984 - 2018.

Maternal deaths are rare events in industrial nations due to high quality medical services. These are often unexpected deaths occurring during pregnancy and labor, thus often requiring forensic autopsies. Our analysis will provide an overview of the expected range of causes of death. A retrospective analysis was carried out on all autopsies performed at the Department of Legal Medicine in Hamburg, Germany, over the last 34 years. Autopsies were carried out on 57 cases of maternal death over the 34- year period, i.e. 1 or 2 cases per year. The average age of women was 30 years. Approximately two thirds of deaths occurred during pregnancy. Cardiovascular events accounted for the leading causes of death from natural causes, suicides were the leading causes of non-natural death. Maternal deaths remained consistently rare over the examination period. There was a wide range of causes of death involving natural and non-natural causes.

A Novel Porcine Circovirus Distantly Related to Known Circoviruses Is Associated with Porcine Dermatitis and Nephropathy Syndrome and Reproductive Failure.

Porcine circovirus-associated disease (PCVAD) is clinically manifested by postweaning multisystemic wasting syndrome (PMWS), respiratory and enteric disease, reproductive failure, and porcine dermatitis and nephropathy syndrome (PDNS). Porcine circovirus 2 (PCV2) is an essential component of PCVAD, although an etiologic role in PDNS is not well established. Here, a novel circovirus, designated porcine circovirus 3 (PCV3), was identified in sows that died acutely with PDNS-like clinical signs. The capsid and replicase proteins of PCV3 are only 37% and 55% identical to PCV2 and bat circoviruses, respectively. Aborted fetuses from sows with PDNS contained high levels of PCV3 (7.57 × 107 genome copies/ml), and no other viruses were detected by PCR and metagenomic sequencing. Immunohistochemistry (IHC) analysis of sow tissue samples identified PCV3 antigen in skin, kidney, lung, and lymph node samples localized in typical PDNS lesions, including necrotizing vasculitis, glomerulonephritis, granulomatous lymphadenitis, and bronchointerstitial pneumonia. Further study of archived PDNS tissue samples that were negative for PCV2 by IHC analysis identified 45 of 48 that were PCV3 positive by quantitative PCR (qPCR), with 60% of a subset also testing positive for PCV3 by IHC analysis. Analysis by qPCR of 271 porcine respiratory disease diagnostic submission samples identified 34 PCV3-positive cases (12.5%), and enzyme-linked immunosorbent assay detection of anti-PCV3 capsid antibodies in serum samples found that 46 (55%) of 83 samples tested were positive. These results suggest that PCV3 commonly circulates within U.S. swine and may play an etiologic role in reproductive failure and PDNS. Because of the high economic impact of PCV2, this novel circovirus warrants further studies to elucidate its significance and role in PCVAD. IMPORTANCE: While porcine circovirus 2 (PCV2) was first identified in sporadic cases of postweaning multisystemic wasting syndrome in Canada in the early 1990s, an epidemic of severe systemic disease due to PCV2 spread worldwide in the ensuing decade. Despite being effectively controlled by commercial vaccines, PCV2 remains one of the most economically significant viruses of swine. Here, a novel porcine circovirus (PCV3) that is distantly related to known circoviruses was identified in sows with porcine dermatitis and nephropathy syndrome (PDNS) and reproductive failure. PCV2, which has previously been associated with these clinical presentations, was not identified. High levels of PCV3 nucleic acid were observed in aborted fetuses by quantitative PCR, and PCV3 antigen was localized in histologic lesions typical of PDNS in sows by immunohistochemistry (IHC) analysis. PCV3 was also identified in archival PDNS diagnostic samples that previously tested negative for PCV2 by IHC analysis. The emergence of PCV3 warrants further investigation.

Diagnostic value of perinatal autopsies: analysis of 486 cases.

AIM: Autopsy is a beneficial procedure to determine the cause of death and the frequency of anomalies in perinatal losses. Even in the event of an autopsy not providing any additional information, completion of the procedure confirming the clinical diagnoses gives reassurance to both clinicians and parents. Here we present a 15-year archival study based on findings of perinatal autopsies. DESIGN AND METHODS: Four hundred and eighty-six cases from our archive were reviewed and according to the findings they were divided into three subcategories; (1) miscarriages (MCF); (2) fetuses terminated (FTA) for vital anomalies detected by prenatal ultrasonography; (3) premature or term newborns died within first month of life (neonates: NN). Autopsies were documented and classified according to week/age of cases, anomalies and causes of abortion or death. RESULTS: Two hundred and twenty-six of 486 cases (46.5%) were in MCF group while 227 (46.7%) and 33 (6.8%) were of them in FTA and NN groups, respectively. In FTA group, the most frequent anomaly detected was neural tube defects. In NN group, prematurity related complications were the most common cause of death. The autopsy process was found valuable in 39.7% of all cases. CONCLUSIONS: We suggest that autopsy procedure is diagnostically valuable even in situations when there is USG findings that are confirming FTAs or there is no important major fetal or placental anomaly detected in MCFs.

Monitoring of Hemostasis and Management of Anticoagulant Thromboprophylaxis in Pregnant Women with Increased Risk of Fetal Loss.

Physiological prothrombotic changes during pregnancy and the postpartum period, along with other preexisting maternal risk factors, increase the risk of both venous thromboembolism (VTE) and adverse pregnancy outcomes. Pregnancy complications that develop due to placental insufficiency as a result of inappropriate activation of coagulation are present in more than 5% of pregnancies and can contribute to significant maternal morbidity and mortality. Therefore, anticoagulant prophylaxis in women with congenital and acquired thrombophilic conditions should be actively considered. According to the Guidelines of American College of Chest Physicians, the use of low-molecular-weight heparin is suggested for prophylaxis of VTE and pregnancy complications in high-risk pregnant women. However, personalized refinements of such thromboprophylaxis remains unspecified, despite the necessity of better targeted recommendations for life-threatening conditions. We, therefore, review the possibilities of longitudinal monitoring and comprehensive assessment of changes in hemostasis in the group of high-risk pregnant women, which can then be used for early prediction and individualization of the optimal anticoagulant thromboprophylaxis of pregnancy complications. Simultaneously, we present our single-center experience with such monitoring and our first series of results.

Birth prevalence and survival of exomphalos in england and wales: 2005 to 2011.

BACKGROUND: Exomphalos occurs in 2.2 per 10,000 births with 76% of these babies surviving to discharge. The aim of this study was to determine the birth prevalence and survival of babies with this anomaly in England and Wales. METHODS: Six BINOCAR regional congenital anomaly registers in England and Wales (covering 36% of births) between 2005 and 2011 provided cases for this study. Cases included live births, stillbirths (24+ weeks' gestation), late miscarriages (20-23 weeks' gestation), and terminations of pregnancy with fetal anomaly. RESULTS: The overall birth prevalence was 3.8 (95% confidence interval [CI]: 3.6-4.0) per 10,000 births; 1.4 (1.2-1.6) for isolated cases, 1.2 (1.1-1.4) for cases with multiple anomalies, and 1.2 (1.1-1.4) for cases with chromosomal anomalies. The live birth prevalence was 0.8 (0.7-0.9), 0.5 (0.4-0.6), and 0.1 (0.0-0.1) per 10,000 live births, respectively. Edwards syndrome, congenital heart defects, and nervous system anomalies were the most common anomalies associated with exomphalos. A prenatal diagnosis was made in 83% of isolated, 95% of multiple, and 99% of chromosomal cases. Fifty-five percent of isolated and multiple cases were live born, whereas 85% of cases with chromosomal anomalies resulted in a termination of pregnancy with fetal anomaly. The 1-year survival of live born babies with an isolated exomphalos was 92% compared with 81% in cases with multiple anomalies and 27% in cases with chromosomal anomalies (p < 0.001). CONCLUSION: We report a higher birth prevalence than has previously been reported. The proportion of infants surviving with exomphalos remained unchanged over the time period.

Atypical antipsychotic drugs and pregnancy outcome: a prospective, cohort study.

Women of childbearing age are often affected with psychotic disorders, requiring the use of antipsychotic medication during pregnancy. In the present study, we prospectively followed the pregnancies of 561 women exposed to second-generation antipsychotic agents (SGAs; study cohort) and compared these to 284 pregnant women exposed to first-generation antipsychotic agents (FGAs; comparison cohort I) and to 1122 pregnant women using drugs known as not harmful to the unborn (comparison cohort II). Subjects were enrolled through the Institute's consultation service. Major malformation rates of SGA exposed were higher compared to comparison cohort II (adjusted odds ratio, 2.17; 95% confidence interval, 1.20-3.91), possibly reflecting a detection bias concerning atrial and ventricular septal defects. Postnatal disorders occurred significantly more often in infants prenatally exposed to SGAs (15.6%) and FGAs (21.6%) compared to 4.2% of comparison cohort II. Cumulative incidences of elective terminations of pregnancy were significantly higher in both the study cohort (17%) and comparison cohort I (21%) compared to comparison cohort II (3%), whereas the rates of spontaneous abortions did not differ. The numbers of stillbirths and neonatal deaths were within the reference range. Preterm birth and low birth weight were more common in infants exposed to FGAs. To conclude, our findings did not reveal a major teratogenic risk for SGAs, making the better studied drugs of this group a treatment option during pregnancy. Because neonates exposed to SGAs or FGAs in the last gestational week are at higher risk of postnatal disorders, delivery should be planned in clinics with neonatal intensive care units.

Causes of Maternal Mortality in Rwanda, 2017-2019.

OBJECTIVE: To assess the causes of maternal mortality at a referral hospital in Rwanda. METHODS: A secondary data analysis of 217 women with recorded maternal mortality from 2017 to 2019 was conducted among 11,308 total maternal admissions. Demographics, diagnosis, management, referring hospital source, and outcomes were recorded. RESULTS: The mean (±SD) age of maternal death was 30.7±7.2 years (range 16-57 years). The overall maternal mortality rate was 1.99%, with yearly rates of 2.45%, 2.53%, and 1.84% in 2017, 2018, and 2019, respectively. A significant seasonal variation was noted. Sepsis was the most common cause of maternal death (50%), followed by hemorrhage (19%) and hypertensive disorders (15%). Causes of maternal deaths included preeclampsia (13%) and abortion (8%). Furthermore, 82% of all the deaths were referrals from smaller community hospitals. CONCLUSION: Maternal death due to sepsis remain a major cause of maternal deaths in Rwanda. Infection prevention and the early diagnosis and management of sepsis must be a priority in reducing maternal mortality.

Miscarriage Treatment-Related Morbidities and Adverse Events in Hospitals, Ambulatory Surgery Centers, and Office-Based Settings.

OBJECTIVE: The aim of the study was to examine whether miscarriage treatment-related morbidities and adverse events vary across facility types. METHODS: A retrospective cohort study compared miscarriage treatment-related morbidities and adverse events across hospitals, ambulatory surgery centers (ASCs), and office-based settings. Data on women who had miscarriage treatment between 2011 and 2014 and were continuously enrolled in their insurance plan for at least 1 year before and at least 6 weeks after treatment were obtained from a large national private insurance claims database. The main outcome was miscarriage treatment-related morbidities and adverse events occurring within 6 weeks of miscarriage treatment. Secondary outcomes were major events and infections. RESULTS: A total of 97,374 miscarriage treatments met inclusion criteria. Most (75%) were provided in hospitals, 10% ASCs, and 15% office-based settings. A total of 9.3% had miscarriage treatment-related events, 1.0% major events, and 1.5% infections. In adjusted analyses, there were fewer events in ASCs (6.5%) than office-based settings (9.4%) and hospitals (9.6%), but no significant difference between office-based settings and hospitals. There were no significant differences in major events between ASCs (0.7%) and office-based settings (0.8%), but more in hospitals (1.1%) than ASCs and office-based settings. There were fewer infections in ASCs (0.9%) than office-based settings (1.2%) and more in hospitals (1.6%) than ASCs and office-based settings. In analyses stratified by miscarriage treatment type, the difference between ASCs and office-based settings was no longer significant for miscarriages treated with procedures. CONCLUSIONS: Although there seem to be slightly more events in hospitals than ASCs or office-based settings, findings do not support limiting miscarriage treatment to particular settings.

Facility-based maternal death review in three districts in the central region of Malawi: an analysis of causes and characteristics of maternal deaths.

PURPOSE: We sought to determine the causes and characteristics maternal deaths that occur in health facilities in Malawi. METHODS: Forty-three maternal deaths were reviewed in 9 hospitals in 3 districts in Central Malawi over a 1-year period. Causes and avoidable factors of maternal deaths were identified during the review, and recommendations made and implemented. MAIN FINDINGS: There were 28 (65.1%) direct obstetric deaths and 15 (34.9%) indirect obstetric deaths. The major causes of maternal deaths were postpartum hemorrhage (25.6%), postpartum sepsis (16.3%), HIV/AIDS (16.3%), ruptured uterus (7.0%), complications of abortion (7.0%), anemia (7.0%), antepartum hemorrhage (4.7), and eclampsia (4.7). Two thirds of the women were referred either from another health facility (51.2%) or by a traditional birth attendant (TBA; 11.6%), and up to 79.1% were critically ill on admission. Four groups of factors that contributed to maternal deaths were identified: 1) health worker factors, 2) administrative factors, 3) patient/family factors, and 4) TBA factors. The major health worker factors were inadequate resuscitation (69.8%), lack of obstetric life-saving skills (60.5%), inadequate monitoring (55.8%), initial assessment incomplete (46.5%), and delay in starting treatment (46.5%). The most common administrative factor was lack of blood for transfusion (20.9%). The major problems encountered include shortage of staff and other resources, difficulty in maintaining anonymity, poor quality of data, and difficulty in implementing recommendations. CONCLUSION: Adequate training on obstetric life-saving skills, addressing HIV/AIDS, and raising community awareness could be important factors for reducing maternal mortality in Malawi and countries with similar socioeconomic profiles.

The frequency of consanguineous marriage in eastern Turkey.

UNLABELLED: The frequency of consanguineous marriage in Eastern Turkey: OBJECTIVE: The rate of consanguineous marriage (CM) varies depended on different factors such as race, characteristics of population, and religion and moral features in different countries. Gene frequency and genetic structure are changed by CMs. The aim of the present study is to assess the prevalence of CM and its effects on miscarriage, stillbirth, congenital malformation and ratio of newborn death. METHODS: This study was performed in Van region, Eastern Turkey, between September 2005 and April 2006. A total of 650 families from 24 districts chosen in accordance with the number of inhabitants were included in this study. First cousin marriages were accepted as a first degree CMs, sesquialter and second cousin marriages as second degree and marriages between distant relatives were accepted as a third degree CM. Monthly income of the families was classified in accordance with minimum wage determined by government. RESULTS: Of all families, 224 (34.4%) had CM, and 168 (75%) had first-degree consanguinity. A lower CM rate was found in mothers who graduated from secondary school or upgrading (p < 0.01). However, no relationship was found between CM and fathers' education level. While a low CM rate was found in families who had two or less children (p < 0.01), high rate was observed in families who had five or more children. In addition, a high rate of miscarriage, stillbirth and mental-motor retardation was found in families with CM (p < 0.05). The rate of child mortality between the aged 0-2 years was found to be higher in families with CM (p < 0.01). The higher CM rate was observed in families who married due to pressure or insistence of their families than married voluntarily (p < 0.05). CONCLUSION: Our study showed that CM rate was very high, 34.4%, in our region Eastern Turkey.

Perinatal outcome in women with bacterial sepsis: A cross-sectional study from West China.

Maternal bacterial sepsis during pregnancy and the postpartum period is a common cause of maternal mortality and fetal morbidity and mortality. This study was performed to analyze perinatal prognosis and related factors of maternal bacterial sepsis in west China.We conducted a cross-sectional study of pregnant women with bacterial sepsis who were admitted into a tertiary care center in western China between 2011and 2015. Data from these cases were collected and analyzed.Eighty six women were identified with bacterial sepsis in our hospital, and the incidence of maternal bacterial sepsis was 1.7 per 1000 maternities, the incidence of septic shock was 1.8 per 10,000 maternities, and 1 maternal death occurred. Among the 86 pregnant women with bacterial sepsis, genital tract infection was the most common source of infection (41/86, 47.7%). The most common bacteria in the Gram-positive bacteria group was Listeria monocytogenes and in the Gram-negative bacteria group was Escherichia coli. The premature delivery rate (65.7%) was substantially higher in the Gram-negative bacteria group (P = .011), and the miscarriage rate (31.3%) was higher in the Gram-positive bacteria group (P = .042). The fetal/neonatal mortality rate was 20% (21/105) and higher in the Gram-positive bacteria group (P = .008), and the infant mortality rate in 1 year was 7.1% (6/84).Bacterial sepsis remains an alarming cause of both maternal and fetal morbidity and mortality, and infant mortality. Key treatment involves a multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women with sepsis and early initiation of appropriate antibiotics according to the type of bacterial infection. The effect of maternal sepsis on long-term fetal outcome should be investigated.

CAUSES OF MATERNAL DEATH IN THE CALLAO REGION, PERÚ. DESCRIPTIVE STUDY, 2000-2015.

OBJETIVE: To identify the causes of maternal mor- tality in the Callao Region between 2000 and 2015. METHODS: Case series study conducted in public and private healthcare institutions in the region of Callao in Perú. Overall, 131 women who met the selection criteria were included as cases of maternal mortality (MM). MM was defined as death of a woman during pregnancy, childbirth or the postpartum period (within the first 42 days after childbirth) in healthcare institutions in Callao. MM clinical-epidemiological records were reviewed. The analysis was performed using percent frequencies and means. RESULTS: Of the causes of MM, 61.1 % were direct and 38.9 % were indirect. The most frequent direct causes were hypertensive disorders of pregnancy, obstetric bleeding and miscarriage. Average time between the onset of discomfort and the decision to ask for assistance was 20 minutes; mean time to arrive at the healthcare institution after making the decision was 20 minutes; and mean delay time between arrival to the institution and provision of care was 7 minutes. Of the total number of maternal deaths, 96.9 % occurred in a healthcare institution. CONCLUSION: The study showed that the causes of MM are mainly of a direct type, primarily due to hypertensive disorders of pregnancy, obstetric bleeding and miscarriage, while indirect causes of MM were less frequent, consisting mainly of infectious causes..

TITULO: CAUSAS DE MUERTE MATERNA EN LA REGIÓN DE CALLAO, PERÚ. ESTUDIO DESCRIPTIVO, 2000-2015. OBJETIVO: Identificar las causas de mortalidad ma- terna en la región de Callao, entre los años 2000 y 2015. METODOS: Estudio de serie de casos en establecimientos de salud (ES) públicos y priva- dos de la región de Callao en Perú. Se incluyeron 131 mujeres como casos de muerte materna (MM) que cumplían los criterios de selección. Se consideró MM, mujer fallecida durante el embarazo, parto o posparto (dentro de los 42 días posparto), en ES del Callao. Se revisaron las historias clínico-epi- demiológicas de MM. El análisis se realizó usando frecuencias porcentuales y promedios. RESULTADOS: El 61,1 % de las causas fueron directas y el 38,9 % indirectas. Las causas directas más frecuentes fueron los trastornos hipertensivos del embarazo, las hemorragias obstétricas y el aborto. La mediana del tiempo que tardó la gestante desde el inicio de las molestias hasta que decidió pedir atención fueron 20 minutos, la mediana del tiempo que tardó en llegar al ES luego de decidir la atención fue de 20 minutos, y la mediana del tiempo de demora desde que llegó la gestante al ES hasta ser atendida fue de 7 minutos. El 96,9 % de las muertes maternas se produjeron en ES. CONCLUSIONES: El estudio demostró que la principal causa de MM es la directa, principalmente debido a trastornos hipertensivos del embarazo; la hemo- rragia obstétrica y el aborto, mientras que en menor proporción fueron las MM indirectas, principal- mente enfermedades infecciosas.

Anticoagulant management of pregnancy following heart valve replacement in the United Kingdom, 1986-2002.

BACKGROUND AND AIM OF THE STUDY: Patients with mechanical heart valves require anticoagulation which is associated with significant maternal mortality (1-4%) and fetal complications (31%) in pregnancy. The study aim was to identify anticoagulant protocols and outcomes for pregnant women undergoing heart valve replacement (HVR) in the United Kingdom. METHODS: Women aged between 18 and 45 years and registered with the United Kingdom Heart Valve Registry (UKHVR) each completed a questionnaire, and their obstetric notes were reviewed. The data analyzed included valve type (mechanical, bioprosthetic, homograft), valve site (mitral, aortic, tricuspid, pulmonary), anticoagulation at confirmation of pregnancy, between 6-12 weeks and from 12 weeks to term, delivery, maternal and fetal outcomes, and cause of death. The summary statistics and a descriptive review of the findings are reported. RESULTS: Of 2,532 women eligible for the study, 922 responded. Among these women, 72 became pregnant, with 60 pregnancies in the mechanical valve (MV) group and 45 in the tissue valve (TV) group. Three anticoagulation regimes were used during early pregnancy: unfractionated heparin (UFH), low-molecular-weight heparin (LMWH) or warfarin. All women received warfarin in the second trimester and heparin for delivery. Live births were recorded in 30% of MV pregnancies and in 60% of TV pregnancies. Miscarriage rates differed markedly (37% MV versus 2% TV). Fetal outcome was poorest in the warfarin-only group, with embryopathy occurring at a dose level of 6 mg. The maternal outcomes did not differ significantly among groups. High-dose heparin during the first trimester and for delivery was effective for the majority of mechanical valves. CONCLUSION: The study results illustrate the diverse and uncertain manner in which UKHVR patients are managed during pregnancy. A national notification system would record much-needed prospective information on anticoagulation and pregnancy outcomes, thus aiding evidence-based management.

Preventability of maternal near miss and mortality in Rwanda: A case series from the University Teaching Hospital of Kigali (CHUK).

OBJECTIVE: Assess the primary causes and preventability of maternal near misses (MNM) and mortalities (MM) at the largest tertiary referral hospital in Rwanda, Kigali University Teaching Hospital (CHUK). METHODS: We reviewed records for all women admitted to CHUK with pregnancy-related complications between January 1st, 2015 and December 31st, 2015. All maternal deaths and near misses, based on WHO near miss criteria were reviewed (Appendix A). A committee of physicians actively involved in the care of pregnant women in the obstetric-gynecology department reviewed all maternal near misses/ pregnancy-related deaths to determine the preventability of these outcomes. Preventability was assessed using the Three Delays Model.[1] Descriptive statistics were used to show qualitative and quantitative outcomes of the maternal near miss and mortality. RESULTS: We identified 121 maternal near miss (MNM) and maternal deaths. The most common causes of maternal near miss and maternal death were sepsis/severe systemic infection (33.9%), postpartum hemorrhage (28.1%), and complications from eclampsia (18.2%)/severe preeclampsia (5.8%)/. In our obstetric population, MNM and deaths occurred in 87.6% and 12.4% respectively. Facility level delays (diagnostic and therapeutic) through human error or mismanagement (provider issues) were the most common preventable factors accounting for 65.3% of preventable maternal near miss and 10.7% maternal deaths, respectively. Lack of supplies, blood, medicines, ICU space, and equipment (system issues) were responsible for 5.8% of preventable maternal near misses and 2.5% of preventable maternal deaths. Delays in seeking care contributed to 22.3% of cases and delays in arrival from home to care facilities resulted in 9.1% of near misses and mortalities. Cesarean delivery was the most common procedure associated with sepsis/death in our population. Previous cesarean delivery (24%) and obstructed/prolonged labor (13.2%) contributed to maternal near miss and mortalities. CONCLUSION: The most common preventable causes of MNM and deaths were medical errors, shortage of medical supplies, and lack of patient education/understanding of obstetric emergencies. Reduction in medical errors, improved supply/equipment availability and patient education in early recognition of pregnancy-related danger signs will reduce the majority of delays associated with MNM and mortality in our population.

Abortion in the Structure of Causes of Maternal Mortality.

OBJECTIVE: To study the structure of maternal mortality caused by abortion in the Tula region. METHODS: The medical records of deceased pregnant women, childbirth, and postpartum from January 01, 2001, to December 31, 2015, were analyzed. RESULTS: Overall, 204,095 abortion cases were recorded in the Tula region for over 15 years. The frequency of abortion was reduced 4-fold, with 18,200 in 2001 to 4,538 in 2015. The rate of abortions per 1,000 women (age 15-44 years) for 15 years decreased by 40.5%, that is, from 46.53 (2001) to 18.84 (2015), and that of abortions per 100 live births and stillbirths was 29.5%, that is, from 161.7 (2001) to 41.5 (2015). Five women died from abortion complications that began outside of the hospital, which accounted for 0.01% of the total number. In the structure of causes of maternal mortality for 15 years, abortion represented 14.3% of the cases. Lethality mainly occurred in the period from 2001 to 2005 (4 cases). Among the maternal deaths, many women died in rural areas after pregnancy termination at 18 to 20 weeks of gestation (n = 4). In addition, three women died from sepsis and two from bleeding. CONCLUSION: The introduction of modern, effective technologies of family planning has reduced maternal mortality due to abortion.

OBJETIVOS: Estudar a estrutura da mortalidade materna causada pelo aborto na região de Tula. MéTODOS: Os registros médicos de mulheres grávidas falecidas, de parto e de pós-parto, de 01 de janeiro de 2001 a 31 de dezembro de 2015, foram analisados. RESULTADOS: No geral, 204.095 casos de aborto foram registrados na região de Tula, em um período de 15 anos. A frequência de aborto foi reduzida a 1/4, passando de 18.200 abortos em 2001 para 4.538 em 2015. A taxa de abortos a cada 1.000 mulheres (com idades entre 15 e 44 anos) diminuiu 40,5% em 15 anos, isto é, de 46,53 (2001) para 18,84 (2015), e a taxa de abortos a cada 100 nascidos vivos e natimortos foi de 29,5%, isto é, de 161,7 (2001) para 41,5 (2015). Cinco mulheres morreram de complicações do aborto que começaram fora do hospital, o que representou 0,01% do número total. No quadro geral de causas de mortalidade materna neste período de 15 anos, o aborto representou 14,3% dos casos. A letalidade ocorreu, principalmente, no período de 2001 a 2005 (4 casos). Entre as mortes maternas, muitas mulheres morreram em áreas rurais após a interrupção da gravidez, com 18 a 20 semanas de gestação (n= 4). Além disso, três mulheres morreram por sepse, e duas, por sangramento. CONCLUSãO: Com a introdução de tecnologias de planejamento familiar modernas e eficazes, a mortalidade materna devido ao aborto vem sendo reduzida.

Abortion in Zimbabwe: A national study of the incidence of induced abortion, unintended pregnancy and post-abortion care in 2016.

BACKGROUND: Zimbabwe has the highest contraceptive prevalence rate in sub-Saharan Africa, but also one of the highest maternal mortality ratios in the world. Little is known, however, about the incidence of abortion and post-abortion care (PAC) in Zimbabwe. Access to legal abortion is rare, and limited to circumstances of rape, incest, fetal impairment, or to save the woman's life. OBJECTIVES: This paper estimates a) the national provision of PAC, b) the first-ever national incidence of induced abortion in Zimbabwe, and c) the proportion of pregnancies that are unintended. METHODS: We use the Abortion Incidence Complications Method (AICM), which indirectly estimates the incidence of induced abortion by obtaining a national estimate of PAC cases, and then estimates what proportion of all induced abortions in the country would result in women receiving PAC. Three national surveys were conducted in 2016: a census of health facilities with PAC capacity (n = 227), a prospective survey of women seeking abortion-related care in a nationally-representative sample of those facilities (n = 127 facilities), and a purposive sample of experts knowledgeable about abortion in Zimbabwe (n = 118). The estimate of induced abortion, along with census and Demographic Health Survey data was used to estimate unintended pregnancy. RESULTS: There were an estimated 25,245 PAC patients treated in Zimbabwe in 2016, but there were critical gaps in their care, including stock-outs of essential PAC medicines at half of facilities. Approximately 66,847 induced abortions (uncertainty interval (UI): 54,000-86,171) occurred in Zimbabwe in 2016, which translates to a national rate of 17.8 (UI: 14.4-22.9) abortions per 1,000 women 15-49. Overall, 40% of pregnancies were unintended in 2016, and one-quarter of all unintended pregnancies ended in abortion. CONCLUSION: Zimbabwe has one of the lowest abortion rates in sub-Saharan Africa, likely due to high rates of contraceptive use. There are gaps in the health care system affecting the provision of quality PAC, potentially due to the prolonged economic crisis. These findings can inform and improve policies and programs addressing unsafe abortion and PAC in Zimbabwe.

Maternal, Fetal, and Neonatal Outcomes in Pregnant Dengue Patients in Mexico.

To increase our understanding of the consequences of dengue virus infection during pregnancy, a retrospective analysis was performed on the medical records of all completed pregnancies (live births and pregnancy losses) at nine public hospitals in the Gulf of Mexico from January to October 2013. Eighty-two patients developed clinical, laboratory-confirmed dengue virus infections while pregnant. Of these, 54 (65.9%) patients were diagnosed with dengue without warning signs, 15 (18.3%) patients were diagnosed with dengue with warning signs, and 13 (15.9%) patients had severe dengue. Five (38.5%) patients with severe dengue experienced fetal distress and underwent emergency cesarean sections. Four patients delivered apparently healthy infants of normal birthweight while the remaining patient delivered a premature infant of low birthweight. Patients died of multiple organ failure during or within 10 days of the procedure. Severe dengue was also associated with obstetric hemorrhage (30.8%, four cases), preeclampsia (15.4%, two cases), and eclampsia (7.7%, one case). These complications were less common or absent in patients in the other two disease categories. Additionally, nonsevere dengue was not associated with maternal mortality, fetal distress, or adverse neonatal outcomes. In summary, the study provides evidence that severe dengue during pregnancy is associated with a high rate of fetal distress, cesarean delivery, and maternal mortality.

Pregnancy-Related Mortality in the United States, 2011-2013.

OBJECTIVE: To update national population-level pregnancy-related mortality estimates and examine characteristics and causes of pregnancy-related deaths in the United States during 2011-2013. METHODS: We conducted an observational study using population-based data from the Pregnancy Mortality Surveillance System to calculate pregnancy-related mortality ratios by year, age group, and race-ethnicity groups. We explored 10 cause-of-death categories by pregnancy outcome during 2011-2013 and compared their distribution with those in our earlier reports since 1987. RESULTS: The 2011-2013 pregnancy-related mortality ratio was 17.0 deaths per 100,000 live births. Pregnancy-related mortality ratios increased with maternal age, and racial-ethnic disparities persisted with non-Hispanic black women having a 3.4 times higher mortality ratio than non-Hispanic white women. Among causes of pregnancy-related deaths, the following groups contributed more than 10%: cardiovascular conditions ranked first (15.5%) followed by other medical conditions often reflecting pre-existing illnesses (14.5%), infection (12.7%), hemorrhage (11.4%), and cardiomyopathy (11.0%). Relative to the most recent report of Pregnancy Mortality Surveillance System data for 2006-2010, the distribution of cause-of-death categories did not change considerably. However, compared with serial reports before 2006-2010, the contribution of hemorrhage, hypertensive disorders of pregnancy, and anesthesia complications declined, whereas that of cardiovascular and other medical conditions increased (population-level percentage comparison). CONCLUSION: The pregnancy-related mortality ratio and the distribution of the main causes of pregnancy-related mortality have been relatively stable in recent years.