ABSTRACT
BACKGROUND: The maternal mortality ratio (MMR) in Indonesia is among the highest in Southeast Asia. We aim to describe trends in the MMR and causes of maternal deaths in Indonesia over the past decades, regionally and nationally. METHODS: We performed a systematic review and conducted a search using PubMed, Embase, Global Health, CINAHL, Cochrane, Portal Garuda, and Google Scholar from the inception of the database to April 2023. We included all studies on the incidence and/or the causes of maternal deaths in Indonesia. The MMR was defined as the number of maternal deaths per 100,000 live births. Maternal death causes were assessed and reclassified according to the WHO International Classification of Disease Maternal Mortality (ICD-MM). RESULTS: We included 63 studies that reported the MMR (54 studies) and/or the causes of maternal deaths (44 studies) in Indonesia from 1970 to 2022, with a total of 254,796 maternal deaths. The national MMR declined from 450 to 249 (45%) between 1990 and 2020. Great differences in MMR exist across the country, with the lowest in Java-Bali and the highest (more than twice the national MMR) in Sulawesi and Eastern Indonesia. Between 1990 and 2022, the proportion of deaths due to hemorrhage and sepsis decreased, respectively from 48 to 18% and 15-5%, while the share of deaths due to hypertensive disorders and non-obstetric causes increased, respectively from 8 to 19% and 10-49%. CONCLUSION: Despite the steady decline of maternal deaths in Indonesia, it remains one of the highest in Southeast Asia, with enormous disparities within the country. Hypertensive disorders and non-communicable diseases make up a growing share of maternal deaths, making maternal death reduction strategies increasingly challenging. National Maternal Death Surveillance and Response needs to be prioritized to eliminate preventable maternal deaths in Indonesia. REGISTRATION OF SYSTEMATIC REVIEWS: PROSPERO, CRD42022320213.
Subject(s)
Cause of Death , Maternal Mortality , Humans , Indonesia/epidemiology , Maternal Mortality/trends , Female , Pregnancy , Cause of Death/trends , Pregnancy Complications/mortality , Pregnancy Complications/epidemiologyABSTRACT
OBJECTIVES: Sepsis is a common cause of maternal mortality and morbidity. Early detection and rapid management are essential. In this study, we evaluate the compliance with the implemented maternity-specific Early Warning Score (EWS), Rapid Response Team (RRT) protocol and the Surviving Sepsis Campaign (SSC) Hour-1 Bundle in a tertiary hospital in the Netherlands. METHODS: We performed a retrospective patient chart review from July 2019 to June 2020 at the Leiden University Medical Centre. We included women who received therapeutic antibiotics and were admitted for at least 24 hours. RESULTS: We included 240 women: ten were admitted twice and one woman three times, comprising 252 admissions. A clinical diagnosis of sepsis was made in 22 women. The EWS was used in 29% (n = 73/252) of admissions. Recommendations on the follow-up of the EWS were carried out in 53% (n = 46/87). Compliance with the RRT protocol was highest for assessment by a medical doctor within 30 minutes (n = 98/117, 84%) and lowest for RRT involvement (n = 7/23, 30%). In women with sepsis, compliance with the SSC Bundle was highest for acquiring blood cultures (n = 19/22, 85%), while only 64% (n = 14/22) received antibiotics within 60 minutes of the sepsis diagnosis. CONCLUSION: The adherence to the maternity-specific EWS and the SSC Hour-1 bundle was insufficient, even within this tertiary setting in a high-income country.
Subject(s)
Guideline Adherence , Sepsis , Tertiary Care Centers , Humans , Female , Netherlands , Tertiary Care Centers/organization & administration , Retrospective Studies , Sepsis/therapy , Sepsis/diagnosis , Guideline Adherence/statistics & numerical data , Adult , Pregnancy , Anti-Bacterial Agents/therapeutic use , Early Warning Score , Practice Guidelines as Topic , Pregnancy Complications, Infectious/drug therapy , Pregnancy Complications, Infectious/therapy , Pregnancy Complications, Infectious/diagnosisABSTRACT
BACKGROUND: Globally, cesarean birth rates are rising, and while it can be a lifesaving procedure, cesarean birth is also associated with increased maternal and perinatal risks. This study aims to describe changes over time about the mode of birth and perinatal outcomes in second-pregnancy women with one previous cesarean birth in the Netherlands over the past 20 years. METHODS: We conducted a nationwide, population-based study using the Dutch perinatal registry. The mode of birth (intended vaginal birth after cesarean (VBAC) compared with planned cesarean birth) was assessed in all women with one previous cesarean birth and no prior vaginal birth who gave birth to a term singleton in cephalic presentation between 2000 and 2019 in the Netherlands (n = 143,146). The reported outcomes include the trend of intended VBAC, VBAC success rate, and adverse perinatal outcomes (perinatal mortality up to 7 days, low Apgar score at 5 min, asphyxia, and neonatal intensive care unit admission ≥24 h). RESULTS: Intended VBAC decreased by 21.5% in women with one previous cesarean birth and no prior vaginal birth, from 77.2% in 2000 to 55.7% in 2019, with a marked deceleration from 2009 onwards. The VBAC success rate dropped gradually, from 71.0% to 65.3%, across the same time period. Overall, the cesarean birth rate (planned and unplanned) increased from 45.2% to 63.6%. Adverse perinatal outcomes were higher in women intending VBAC compared with those planning a cesarean birth. Perinatal mortality initially decreased but remained stable from 2009 onwards, with only minimal differences between both modes of birth. CONCLUSIONS: In the Netherlands, the proportion of women intending VBAC after one previous cesarean birth and no prior vaginal birth has decreased markedly. Particularly from 2009 onwards, this decrease was not accompanied by a synchronous reduction in perinatal mortality.
Subject(s)
Drug Hypersensitivity , Hypersensitivity, Delayed , Hypersensitivity , Drug Hypersensitivity/diagnosis , Drug Hypersensitivity/etiology , Humans , Hyaluronoglucosaminidase/adverse effects , Hypersensitivity/complications , Hypersensitivity, Delayed/chemically induced , Hypersensitivity, Delayed/complications , Hypersensitivity, Delayed/diagnosisABSTRACT
Naturally found chrysosplenol-C (4',5,6-trihydroxy-3,3',7-trimethoxyflavone) increases the contractility of cardiac myocytes independent of ß-adrenergic signaling. We investigated the cellular mechanism for chrysosplenol-C-induced positive inotropy. Global and local Ca2+ signals, L-type Ca2+ current (ICa), and contraction were measured from adult rat ventricular myocytes using two-dimensional confocal Ca2+ imaging, the whole-cell patch-clamp technique, and video-edge detection, respectively. Application of chrysosplenol-C reversibly increased Ca2+ transient magnitude with a maximal increase of â¼55% within 2- to 3-minute exposures (EC50 â 21 µM). This chemical did not alter ICa and slightly increased diastolic Ca2+ level. The frequency and size of resting Ca2+ sparks were increased by chrysosplenol-C. Chrysosplenol-C significantly increased sarcoplasmic reticulum (SR) Ca2+ content but not fractional release. Pretreatment of protein kinase C (PKC) inhibitor but not Ca2+/calmodulin-dependent protein kinase II (CaMKII) inhibitor abolished the stimulatory effects of chrysosplenol-C on Ca2+ transients and Ca2+ sparks. Chrysosplenol-C-induced positive inotropy was removed by the inhibition of PKC but not CaMKII or phospholipase C. Western blotting assessment revealed that PKC-δ protein level in the membrane fractions significantly increase within 2 minutes after chrysosplenol-C exposure with a delayed (5-minute) increase in PKC-α levels in insoluble membrane. These results suggest that chrysosplenol-C enhances contractility via PKC (most likely PKC-δ)-dependent enhancement of SR Ca2+ releases in ventricular myocytes. SIGNIFICANCE STATEMENT: Study shows that chrysosplenol-C, a natural flavone showing a positive inotropic effect, increases SR Ca2+ releases on depolarizations and Ca2+ sparks with an increase of SR Ca2+ loading but not L-type Ca2+ current in ventricular myocytes. Chrysosplenol-C-induced enhancement in contraction is eliminated by PKC inhibition, and it is associated with redistributions of PKC to the membrane. These indicate that chrysosplenol-C enhances contraction via PKC-dependent augmentations of SR Ca2+ release and Ca2+ loading during action potentials.
Subject(s)
Calcium/metabolism , Flavonoids/pharmacology , Myocardial Contraction/drug effects , Myocytes, Cardiac/metabolism , Protein Kinase C/metabolism , Sarcoplasmic Reticulum/metabolism , Animals , Dose-Response Relationship, Drug , Heart Ventricles/cytology , Heart Ventricles/drug effects , Heart Ventricles/metabolism , Male , Myocardial Contraction/physiology , Myocytes, Cardiac/drug effects , Protein Kinase C/antagonists & inhibitors , Rats , Rats, Sprague-Dawley , Sarcoplasmic Reticulum/drug effectsABSTRACT
With the expansion of the COVID-19 vaccination drive, an increasing number of adverse effects are surfacing. A 74-year-old woman presented with multiple erythematous and itchy patches on several sites. She had no relevant medical history, apart from the first AZD1222 vaccination 1 month previously. Microscopically, epidermal changes, including mild spongiosis and parakeratosis, were observed. Tight perivascular lymphocytic infiltration (coat-sleeve pattern) was also observed in the dermis. The final diagnosis was erythema annulare centrifugum (EAC) induced by SARS-CoV-2 vaccination. Based on this report, dermatologists should be aware of the possibility of EAC from the AZD1222 vaccination.
Subject(s)
COVID-19 Vaccines/adverse effects , Erythema/chemically induced , Skin Diseases, Genetic/chemically induced , Aged , Female , HumansABSTRACT
A stimbiotic is defined as a product that stimulates a fiber-degrading microbiome to increase fiber fermentability. The aim of this study was to examine if it is more advantageous to feed a stimbiotic (xylanase + xylo-oligosaccharides [STB]) or a combination of xylanase and beta-glucanase (Xyl + BG) to broilers fed wheat-barley based diets with differing AME levels. Cobb 500 broilers (n = 480, 80 birds per treatment) were fed 6 dietary treatments in a 2 × 3 factorial arrangement; 2 AME levels, 'High' or 'Low', which differed by 100 kcal ME/kg, and 3 additive supplementations, with no supplemental additives, STB or Xyl + BG. Diets were fed as 3 phases, starter (d 0-14), grower (d 14-21) and finisher (d 21-35). On bird age d 14, 21 and 35, total pen body weight and feed intake were determined, and feed conversion ratio corrected for mortality (cFCR) was calculated. On d 21 and d 35 ileal viscosity and beta-glucan content and caecal SCFA concentration were determined. Additive suplementation had no impact on cFCR in birds fed the low AME diet, but in birds fed the high AME diet the cFCR value was reduced in the presence of the additives (P = 0.001 and P = 0.015, at d 14-21 and d 21-35, respectively). At d 21, cecal SCFA concentration was consistently higher (P = 0.015), and ileal beta-glucan level lower (P = 0.002), in birds fed the diet supplemented with STB compared to those without additives. At d 35, ileal viscosity was lower in birds fed STB compared to those fed the diet without supplementation of additives, irrespective of diet AME level (P = 0.017). These results suggest that both STB and Xyl + BG ameliorate the antinutritive effects of the non-starch polysaccharides (NSP) present in wheat-barley based diets, resulting in improved bird performance. However, supplementation with STB induces a comparatively greater positive effect on NSP hydrolysis and SCFA production.
Subject(s)
Animal Nutritional Physiological Phenomena , Hordeum , Animals , Animal Feed/analysis , Chickens , Diet/veterinary , Dietary Supplements , Digestion , TriticumABSTRACT
Implementation of maternal death surveillance and response (MDSR) is crucial to reduce maternal deaths. In Suriname, MDSR was not implemented until 2015. We describe the process of MDSR implementation in Suriname and share the "lessons learned," as experienced by the health care providers, national maternal death review committee members, and public health experts. Before 2015, maternal deaths were identified using death certificates and by active surveillance in the hospitals. Based on the recommendations from a 2010-2014 Reproductive Age Mortality Survey in Suriname, a maternal death review committee has improved the identification of maternal deaths and has audited every death since 2015. Although this review committee initiated several actions to implement MDSR together with health care providers, the involvement of the Ministry of Health (MOH) was crucial. Therefore, the Maternal Health Steering Committee was recently installed as a direct working arm of MOH to guide MDSR implementation. One of the main barriers to implementing MDSR in Suriname has been the lack of action following recommendations. Delineating roles and responsibilities for action, establishing accountability mechanisms, and influencing stakeholders in a position to act are critical to ensure a response to the recommendations. To implement MDSR, the 5 Cs-commitment, "no blame, no shame" culture, coordination, collaboration, and communication-are crucial.
Subject(s)
Maternal Death , Health Personnel , Humans , Maternal Death/prevention & control , Maternal Mortality , SurinameABSTRACT
The susceptibility of Acinetobacter baumannii exposed to primary antibiotic can be either increased or decreased when exposed to secondary antibiotic. This study was designed to assess the relative fitness, collateral susceptibility and collateral resistance of polymyxin B- (PMB-) adapted A. baumannii to ciprofloxacin (CIP), meropenem (MER), PMB, tetracycline (TET) and tobramycin (TOB). Strains of wild-type A. baumannii KACC 12454 (ABKACC ), wild-type A. baumannii CCARM 12088 (ABCCARM ), PMB-adapted ABKACC , PMB-adapted ABCCARM , stabilized ABKACC and stabilized ABCCARM were used in this study. Compared to the wild-type ABKACC , the MICs of PMB were increased from 2 to 128 µg ml-1 against PMB-adapted ABKACC , while MICs of CIP, MER, TET and TOB were decreased from 2 to 1 µg ml-1 , 16 to 1 µg ml-1 , 16 to 2 µg ml-1 and 64 to 16 µg ml-1 , respectively. The PMB-adapted ABCCARM was resistant to CIP (32 µg ml-1 ) and PMB (64 µg ml-1 ) compared to the wild-type ABCCARM . The resistance of stabilized ABKACC and ABCCARM to all antibiotics was lost after antibiotic-free culture in the exception of CIP and TET. The susceptibilities of wild-type, PMB-adapted and stabilized ABKACC and ABCCARM to CIP, MER, PMB, TET and TOB were increased in the presence of ß-lactamase and efflux pump inhibitors. The high levels of relative fitness were observed for stabilized ABKACC , PMB-adapted ABCCARM and stabilized ABCCARM . The stabilized ABKACC and PMB-adapted ABCCARM were highly heteroresistance to PMB and TET, respectively. The PMB-adapted ABKACC and ABCCARM showed various antibiotic patterns, known as collateral susceptibility and collateral resistance. The results provide useful information for designing effective antibiotic regimens that can enhance the antibiotic activity against A. baumannii infections.
Subject(s)
Acinetobacter baumannii/drug effects , Adaptation, Biological , Anti-Bacterial Agents/pharmacology , Drug Collateral Sensitivity , Acinetobacter Infections/drug therapy , Acinetobacter Infections/microbiology , Ciprofloxacin/pharmacology , Drug Resistance, Multiple, Bacterial , Humans , Meropenem/pharmacology , Microbial Sensitivity Tests , Polymyxin B/pharmacology , Tetracycline/pharmacology , Tobramycin/pharmacology , beta-Lactamases/pharmacologyABSTRACT
OBJECTIVE: This retrospective study investigated the nature and severity of venom-induced consumption coagulopathy (VICC) and determined the clotting factors involved in VICC in patients after envenomation by South Korea's snakes. Additionally, we studied the effectiveness of antivenom for the treatment of VICC after envenomation. METHODS: Included patients were divided into three groups according to the severity of VICC (no VICC, partial VICC, and complete VICC). Data, including changes in coagulation parameters during hospitalization and clotting factors at presentation, were collected and analyzed. RESULTS: One hundred nineteen patients who presented at our emergency department within 3 h after snake envenomation were included. VICC developed in 34 patients (27 patients with partial VICC and 7 patients with complete VICC). Two of 34 patients with VICC required blood transfusions. Five patients with complete VICC had an undetectable fibrinogen concentration at presentation. Three patients with complete VICC had an unmeasurable INR and aPTT within 24 h. The median times of the most extreme values were 10 h for INR, 12 h for aPTT, and 16 h for fibrinogen after presentation in the VICC group. The D-dimer concentration peaked at a median of 63.5 h after presentation. The activities of factors II and X were significantly reduced in the complete VICC group (factor II: 88 (84-99.3)% in the non-VICC group vs. 69 (49.5-83.5)% in the complete VICC group; factor X:94 (83-102) in the non-VICC group vs. 70 (66.5-79.8)% in the complete VICC group), while there was no difference in factor V activity at presentation. The time from bite to first antivenom administration did not correlate with the time course and most extreme concentrations for fibrinogen and D-dimer within the VICC groups. DISCUSSION AND CONCLUSION: VICC occurs in approximately one-quarter of snakebite patients in South Korea; however, VICC itself does not appear to lead to clinical deterioration. Fibrinogen is an early diagnostic maker for complete VICC. Clotting factors II and X are involved in VICC. Future investigations should explore the mechanism of VICC from Korean snakebites and the effect of antivenom on VICC.
Subject(s)
Blood Coagulation , Disseminated Intravascular Coagulation/etiology , Snake Bites/complications , Snake Venoms/antagonists & inhibitors , Snakes , Aged , Animals , Antivenins/therapeutic use , Biomarkers/blood , Blood Coagulation/drug effects , Blood Coagulation Tests , Disseminated Intravascular Coagulation/blood , Disseminated Intravascular Coagulation/diagnosis , Disseminated Intravascular Coagulation/drug therapy , Factor X/metabolism , Female , Fibrinogen/metabolism , Humans , Male , Middle Aged , Prothrombin/metabolism , Republic of Korea , Retrospective Studies , Severity of Illness Index , Snake Bites/blood , Snake Bites/diagnosis , Snake Bites/drug therapy , Snake Venoms/metabolism , Time Factors , Treatment OutcomeABSTRACT
There is a need for effective wound healing through rapid wound closure, reduction of scar formation, and acceleration of angiogenesis. Hydrogel is widely used in tissue engineering, but it is not an ideal solution because of its low vascularization capability and poor mechanical properties. In this study, gelatin methacrylate (GelMA) was tested as a viable option with tunable physical properties. GelMA hydrogel incorporating a vascular endothelial growth factor (VEGF) mimicking peptide was successfully printed using a three-dimensional (3D) bio-printer owing to the shear-thinning properties of hydrogel inks. The 3D structure of the hydrogel patch had high porosity and water absorption properties. Furthermore, the bioactive characterization was confirmed by cell culture with mouse fibroblasts cell lines (NIH 3T3) and human umbilical vein endothelial cells. VEGF peptide, which is slowly released from hydrogel patches, can promote cell viability, proliferation, and tubular structure formation. In addition, a pig skin wound model was used to evaluate the wound-healing efficacy of GelMA-VEGF hydrogel patches; the results suggest that the GelMA-VEGF hydrogel patch can be used for wound dressing.
Subject(s)
Hydrogels , Methacrylates , Vascular Endothelial Growth Factor A , Wound Healing/drug effects , Animals , Bandages , Cells, Cultured , Human Umbilical Vein Endothelial Cells/cytology , Humans , Hydrogels/chemistry , Hydrogels/pharmacology , Methacrylates/chemistry , Methacrylates/pharmacology , Peptides/chemistry , Peptides/pharmacology , Printing, Three-Dimensional , Swine , Vascular Endothelial Growth Factor A/chemistry , Vascular Endothelial Growth Factor A/pharmacologyABSTRACT
The World Health Organization (WHO) provides a framework (ICD-MM) to classify pregnancy-related deaths systematically, which enables global comparison among countries. We compared the classification of pregnancy-related deaths in Suriname by the attending physician and by the national maternal death review (MDR) committee and among the MDR committees of Suriname, Jamaica and the Netherlands. There were 89 possible pregnancy-related deaths in Suriname between 2010 and 2014. Nearly half (47%) were classified differently by the Surinamese MDR committee as compared to the classification of the attending physicians. All three MDR committees agreed that 18% (n = 16/89) of the cases were no maternal deaths. Out of the remaining 73 cases, there was disagreement regarding whether 15% (n = 11) were maternal deaths. The Surinamese and Jamaican MDR committees achieved greater consensus in classification than the Surinamese and the Netherlands MDR committees. The Netherlands MDR committee classified more deaths as unspecified than Surinamese and the Jamaican MDR committees. Underlying causes that achieved a high level of agreement among the three committees were abortive outcomes and obstetric hemorrhage, while little agreement was reported for unspecified and other direct causes. The issues encountered during maternal death classification using the ICD-MM guidelines included classification of suicide during early pregnancy; when to assume pregnancy without objective evidence; how to count maternal deaths occurring outside the country of residence; the relevance of direct or indirect cause attribution; and how to select the underlying cause when direct and indirect conditions or multiple comorbidities co-occur. Addressing these classification barriers in future revisions of the ICD-MM guidelines could enhance the feasibility of maternal death classification and facilitate global comparison. BACKGROUND: Insight into the underlying causes of pregnancy-related deaths is essential to develop policies to avert preventable deaths. The WHO International Classification of Diseases-Maternal Mortality (ICD-MM) guidelines provide a framework to standardize maternal death classifications and enable comparison in and among countries over time. However, despite the implementation of these guidelines, differences in classification remain. We evaluated consensus on maternal death classification using the ICD-MM guidelines. METHODS: The classification of pregnancy-related deaths in Suriname during 2010-2014 was compared in the country (between the attending physician and the national maternal death review (MDR) committee), and among the MDR committees from Suriname, Jamaica and the Netherlands. All reviewers applied the ICD-MM guidelines. The inter-rater reliability (Fleiss kappa [κ]) was used to measure agreement. RESULTS: Out of the 89 cases certified by attending physicians, 47% (n = 42) were classified differently by the Surinamese MDR committee. The three MDR committees agreed that 18% (n = 16/89) of these cases were no maternal deaths, and, therefore, excluded from further analyses. However, opinions differed whether 15% (n = 11) of the remaining 73 cases were maternal deaths. The MDR committees achieved moderate agreement classifying the deaths into type (direct, indirect and unspecified) (κ = 0.53) and underlying cause group (κ = 0.52). The Netherlands MDR committee classified more maternal deaths as unspecified (19%), than the Jamaican (7%) and Surinamese (4%) committees did. The mutual agreement between the Surinamese and Jamaican MDR committees (κ = 0.69 vs κ = 0.63) was better than between the Surinamese and the Netherlands MDR committees (κ = 0.48 vs κ = 0.49) for classification into type and underlying cause group, respectively. Agreement on the underlying cause category was excellent for abortive outcomes (κ = 0.85) and obstetric hemorrhage (κ = 0.74) and fair for unspecified (κ = 0.29) and other direct causes (κ = 0.32). CONCLUSIONS: Maternal death classification differs in Suriname and among MDR committees from different countries, despite using the ICD-MM guidelines on similar cases. Specific challenges in applying these guidelines included attribution of underlying cause when comorbidities occurred, the inclusion of deaths from suicides, and maternal deaths that occurred outside the country of residence.
Subject(s)
Cause of Death , Maternal Death/classification , Physicians , Suicide , Advisory Committees , Female , Humans , International Classification of Diseases , Jamaica , Maternal Mortality , Netherlands/epidemiology , Pregnancy , Suriname/epidemiology , World Health OrganizationABSTRACT
BACKGROUND: The Sustainable Development Goal target 3.1 aims to reduce the global maternal mortality ratio to less than 70 per 100,000 live births. Great disparities reported in maternal mortality ratio between and within countries make this target unachievable. To gain more insight into such disparities and to monitor and describe trends, confidential enquiries into maternal deaths are crucial. OBJECTIVE: We aimed to study the trend in maternal mortality ratio, causes, delay in access and quality of care, and "lessons learned" in Suriname, over almost 3 decades with 3 confidential enquiries into maternal deaths and provide recommendations to prevent maternal deaths. STUDY DESIGN: The third national confidential enquiry into maternal deaths was conducted between 2015 and 2019 in Suriname by prospective, population-based surveillance and multidisciplinary systematic maternal death review. Subsequently, a comparative analysis with previous confidential enquiry into maternal deaths was performed: confidential enquiry into maternal deaths I (a prospective study, 1991-1993) and confidential enquiry into maternal deaths II (a retrospective study, 2010-2014). RESULTS: We identified 62 maternal deaths and recorded 48,881 live births (maternal mortality ratio, 127/100,000 live births) between 2015-2019. Of the women who died, 14 of 62 (23%) were in poor condition when entering a health facility, whereas 11 of 62 (18%) died at home or during transportation. The maternal mortality ratio decreased over the years, (226 [n=64]; 130 [n=65]; and 127 [n=62]), with underreporting rates of 62%, 26%, and 24%, respectively in confidential enquiry into maternal deaths I, II and III. Of the women deceased, 36 (56%), 37 (57%), and 40 (63%) were of African descent; 46 (72%), 45 (69%), and 47 (76%) died after birth; and 47 (73%), 55 (84%), and 48 (77%) died in the hospital, respectively, in confidential enquiries into maternal deaths I, II, and III. Significantly more women were uninsured in confidential enquiry into maternal deaths III (15 of 59 [25%,]) than in confidential enquiry into maternal deaths II (0%) and I (6 of 64 [9%]). Obstetrical hemorrhage was less often the underlying cause of death over the years (19 of 64 [30%], vs 13 of 65 [20%], vs 7 of 62 [11%]), whereas all other obstetrical causes occurred more often in confidential enquiry into maternal deaths III (eg, suicide [0; 1 of 65 (2%); 5 of 62 (8%)]) and unspecified deaths (1 of 64 [2%]; 3 of 65 [5%]; and 11 of 62 [18%] in confidential enquiry into maternal deaths I, II and III respectively). Maternal deaths were preventable in nearly half of the cases in confidential enquiry into maternal deaths II (28 of 65) and III (29 of 62). Delay in quality of care occurred in at least two-thirds of cases (41 of 62 [65%], 47 of 59 [80%], and 47 of 61 [77%]) over the years. CONCLUSION: Suriname's maternal mortality rate has decreased throughout the past 3 decades, yet the trend is too slow to achieve the Sustainable Development Goal 3.1. Preventable maternal deaths can be reduced by ensuring high-quality facility-based obstetrical and postpartum care, universal access to care especially for vulnerable women (of African descent and low socioeconomic class), and by addressing specific underlying causes of maternal deaths.
ABSTRACT
BACKGROUND: Latin America and the Caribbean is the region with the highest prevalence of hypertensive disorders of pregnancy worldwide. In Suriname, where the stillbirth rate is the second highest in the region, it is not yet known which maternal factors contribute most substantially. OBJECTIVE: The aims of this study in Suriname were to (1) study the impact of different types of maternal morbidity on adverse perinatal outcomes and (2) study perinatal birth outcomes among women with severe hypertensive disorders of pregnancy. STUDY DESIGN: A case-control study was conducted between March 2017 and February 2018 during which time all hospital births (86% of total) in Suriname were included. We identified babies with adverse perinatal outcomes (perinatal death or neonatal near miss) and women with severe maternal morbidity (according to the World Health Organization Near Miss tool). Stillbirths and early neonatal deaths (<7 days) were considered perinatal death. We defined a neonatal near miss as a birthweight below 1750 g, gestational age <33 weeks, 5-minute Apgar score <7, and preterm intrauterine growth restriction
ABSTRACT
CONTENT: This study investigated the incidence, progression and clinical course of myocardial injury-related snake envenomation in South Korea. In addition, this study evaluated whether antivenom guidelines are appropriate to control envenomation in patients with myocardial injury. METHODS: The study included 198 patients who received antivenom after a snakebite, and they were divided into two groups according to evidence of myocardial injury (defined as elevated troponin I or ischemic change on electrocardiogram) at presentation. Data including serial troponin I, echocardiogram/coronary angiogram findings, the clinical course, and treatment were collected and analyzed. RESULTS: The incidence of myocardial injury at presentation was 15.2%. The troponin I level was 0.11 (0.07-0.56) ng/ml at presentation and tended to decrease over 24 h. Echocardiograms revealed neither regional wall motion abnormalities nor left ventricular dysfunction in 15 of 17 patients, while two patients showed signs of coronary artery stenosis on echocardiograms and coronary angiograms. However, compared with patients without myocardial injury, patients with myocardial injury had a higher frequency of systemic envenomation complications, including bleeding, respiratory failure, hypotension, acute kidney injury, thrombocytopenia and venom-induced consumption coagulopathy (VICC). The patients with myocardial injury at presentation needed significantly more frequent and larger doses of antivenom than indicated by the initial severity of envenomation. Multivariate analysis showed that myocardial injury was associated with the need for additional antivenom administration after initial administration. DISCUSSION AND CONCLUSION: Myocardial injury is not uncommon after snake envenomation in Korea. Although myocardial injury itself seems to be benign, the clinical course of patients with myocardial injury is complicated, and myocardial injury is associated with the need for additional antivenom administration. The optimal use of antivenom to control envenomation in patents with myocardial injury after snake envenomation in South Korea should be established.
Subject(s)
Antivenins/therapeutic use , Cardiomyopathies/etiology , Snake Bites/physiopathology , Snake Bites/therapy , Aged , Cardiomyopathies/epidemiology , Cardiomyopathies/physiopathology , Electrocardiography , Female , Humans , Incidence , Male , Middle Aged , Practice Guidelines as Topic , Republic of Korea/epidemiology , Retrospective Studies , Snake Bites/epidemiology , Time-to-Treatment , Treatment Outcome , Troponin I/bloodABSTRACT
BACKGROUND: The incidence of skin cancer is increasing because of the ageing population and ultraviolet exposure, and previous studies have revealed that long-term use of hydrochlorothiazide (HCTZ), an antihypertensive agent, has been associated with an increased risk of nonmelanoma skin cancer (NMSC). However, the association of NMSC and HCTZ within East Asian populations is unclear. AIM: To investigate the risk of NMSC in Korean subjects using HCTZ. METHODS: A retrospective cohort study was conducted using the administrative healthcare data. The study enrolled 62 243 patients exposed to HCTZ with a cumulative dose of ≥ 2500 mg and 62 243 unexposed subjects matched 1 : 1 with the patients for age, sex and income level. RESULTS: There was a significant difference in the cumulative incidence of NMSC between the two groups (log-rank P < 0.01). Cox regression analysis was conducted after adjusting for potential confounders, and showed the risk for NMSC in the group exposed to HCTZ was significantly higher than that of the unexposed group (hazard ratio = 1.48; 95% CI 1.03-2.13). In the subgroup analysis, the oldest age group (≥ 70 years) showed increased cumulative incidence of NMSC with statistical significance compared with the unexposed control group (log-rank P < 0.01). CONCLUSIONS: In this study, we revealed that the cumulative use of HCTZ (≥ 2500 mg) could increase the risk of NMSC in Koreans, especially the older age group. Thus, HCTZ could be a risk factor for NMSC in East Asian as well as white populations.
Subject(s)
Antihypertensive Agents/adverse effects , Hydrochlorothiazide/adverse effects , Skin Neoplasms/etiology , Age Factors , Aged , Female , Humans , Incidence , Kaplan-Meier Estimate , Male , Middle Aged , Proportional Hazards Models , Republic of Korea/epidemiology , Retrospective Studies , Risk Factors , Skin Neoplasms/epidemiologyABSTRACT
BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of direct maternal mortality globally and in Suriname. We aimed to study the prevalence, risk indicators, causes, and management of PPH to identify opportunities for PPH reduction. METHODS: A nationwide retrospective descriptive study of all hospital deliveries in Suriname in 2017 was performed. Logistic regression analysis was applied to identify risk indicators for PPH (≥ 500ml blood loss). Management of severe PPH (blood loss ≥1,000ml or ≥500ml with hypotension or at least three transfusions) was evaluated via a criteria-based audit using the national guideline. RESULTS: In 2017, the prevalence of PPH and severe PPH in Suriname was 9.2% (n = 808/8,747) and 2.5% (n = 220/8,747), respectively. PPH varied from 5.8% to 15.8% across the hospitals. Risk indicators associated with severe PPH included being of African descent (Maroon aOR 2.1[95%CI 1.3-3.3], Creole aOR 1.8[95%CI 1.1-3.0]), multiple pregnancy (aOR 3.4[95%CI 1.7-7.1]), delivery in Hospital D (aOR 2.4[95%CI 1.7-3.4]), cesarean section (aOR 3.9[95%CI 2.9-5.3]), stillbirth (aOR 6.4 [95%CI 3.4-12.2]), preterm birth (aOR 2.1[95%CI 1.3-3.2]), and macrosomia (aOR 2.8 [95%CI 1.5-5.0]). Uterine atony (56.7%, n = 102/180[missing 40]) and retained placenta (19.4%, n = 35/180[missing 40]), were the main causes of severe PPH. A criteria-based audit revealed that women with severe PPH received prophylactic oxytocin in 61.3% (n = 95/155[missing 65]), oxytocin treatment in 68.8% (n = 106/154[missing 66]), and tranexamic acid in 4.9% (n = 5/103[missing 117]). CONCLUSIONS: PPH prevalence and risk indicators in Suriname were similar to international and regional reports. Inconsistent blood loss measurement, varied maternal and perinatal characteristics, and variable guideline adherence contributed to interhospital prevalence variation. PPH reduction in Suriname can be achieved through prevention by practicing active management of the third stage of labor in every birth and considering risk factors, early recognition by objective and consistent blood loss measurement, and prompt treatment by adequate administration of oxytocin and tranexamic acid according to national guidelines.