A collaborative framework for managing pregnancy loss in the emergency department.

The purpose of this article is to examine how nurses can improve comprehensive care for women who suffer an early pregnancy loss in the emergency department and highlight the integral role of obstetric and emergency department nurses within a new holistic framework of collaborative care. These nurses are integral in the proposed collaborative "fetal loss framework," which provides an innovative approach for holistic care for this population.

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.

A hospital-based study of abortion in Nepal.

This report presents the major findings of a study of induced abortion in Nepal, based on 165 cases out of the 1,576 female patients identified as having abortion-related complications who were admitted to five major hospitals in urban Nepal during a one-year study period. Traditional birth attendants had been the service providers for two-fifths of the women. A longer delay in hospital referrals and lengthier hospital stays occurred for cases of induced abortion than for those of spontaneous abortion. Twelve of the 165 women in the study died in the hospital, most of them from tetanus. Deaths resulting from abortion-related complications represented more than half of all maternity-related deaths in the hospitals studied. The authors suggest that health risks could be reduced considerably by strengthening the hospital-referral system and by taking some preventive steps, such as educating the traditional birth attendants and other paramedical providers about the consequences of unsafe abortion practices; increasing the availability of contraceptive methods; and promoting the use of menstrual regulation, which has recently become available in Nepal on a limited scale, mostly in private clinics.

Incidence and causes of maternal mortality in five Kampala hospitals, 1980-1986.

This report presents results of a descriptive study to estimate the mortality rate, identify the type and the causes of maternal deaths. The study was conducted in 1987 in Kampala hospitals for a period covering seven years from 1st January 1980 to 31st December, 1986. The non abortion maternal mortality rate (NAMMR) was 2.65 per 1000 deliveries while the abortion related maternal mortality rate (ARMMR) was 3.58 per 1000 abortions. There was a statistically significant increase in NAMMR while the increase in ARMMR was almost significant over the seven year period. Of all maternal deaths, 80 per cent were non abortion while 20 per cent were abortion related. The commonest immediate causes of death, in order of importance, were sepsis, haemorrhage, ruptured uterus, anaesthesia and anaemia. The commonest patient management factors which contributed to death, in order of importance, were lack of blood for transfusion, lack of drugs and intravenous fluids, theatre problems and doctor related factors. We feel that a lot happens to the pregnant mother before she finally reaches a health unit for delivery and that there is a great need to improve on the community's gynaecological and obstetrical services as well as ambulance and emergency services. We also feel that maternal mortality in developing countries could be reduced if the health workers were imaginative in respect to each patient, tried not to operate as though they were working in a developed country, and created relevant solutions for the local problems.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: Maternal mortality is examined from June 1980 to December 1986 at Mulago, Nsambyo, Old Kampala, Rubaga, and Mengo Hospitals in Kampala, Uganda. Clinical or immediate causes, direct and indirect, were recorded from case summary forms based on ICD9 definitions of obstetric complications. The nonabortion maternal mortality rate (NAMMR) was 2.65/1000 deliveries (580 deaths); the abortion-related maternal mortality rate (ARMMR) was 3.58/1000 abortions. The hospital maternal mortality rate was 2.0/1000 deliveries. 75% of maternal deaths of women of 28 weeks' gestation or more had delivered outside the hospital. NAMMR doubled between 1980-86, a statistically significant increase. ARMMR increases were almost significant. 75% were direct obstetric and 21% were indirect obstetric causes. 38% had clinical anemia, 29% had some sepsis, 18% had substantial bleeding, and 14% had obstructed labor. Other contributing conditions were pneumonia, ruptured uterus, laparotomy, evacuations and curettage, malaria, preeclampsia, sickle cell anemia, pulmonary embolism, malnutrition, tetanus, meningitis, prolonged labor, and hepatitis. At admission, 48% were in poor condition, 30% in good condition, and 22% in fair condition. 27% had sickle cell anemia, high blood pressure, multiple pregnancy, or malaria at admission. 64% were admitted within 24 hours after delivery, 67% 1-7 days after delivery, and 92% 7-42 days after delivery. Those in good condition were all admitted 7 days postdelivery. 41% of deaths were due to lack of drugs, 7% lack of fluids, 20% with theater problems, 14% with doctor-related factors, and 3% with midwife-related factors. Better information is needed on mortality before delivery, mortality in hospitals vs. outside, and mortality from abortion, and ectopic and hydatidiform molar pregnancies. An explanation given for the increase in maternal mortality is the decline in economic conditions. Abortion complications may be due to the concealment practiced. Causes are consistent with trends from the 1950s, 1960s, and 1970s in Uganda and developing countries in general. Availability and accessibility of gynecological and obstetric services needs great improvement. Training traditional birth attendants and obtaining rural ambulance services are also needed. Health workers lack creativity and imagination for developing country conditions; scarce resources are not the only problem.