Maternal deaths in Norway 2005-2009.

BACKGROUND: Norway has low maternal mortality, but such deaths are underreported even in high-income countries. Our goal was to identify the exact number of maternal deaths, the causes of death and the potential for improvement through medical care in Norway. MATERIAL AND METHOD: We traced maternal deaths in the period from 1 January 2005 to 31 December 2009 by linking the Medical Birth Registry and the Cause of Death Registry, supplemented with data from maternity clinics. We identified the cause of death and the lessons that could be learned by a meticulous review of each case. RESULTS: We found 26 maternal deaths during the period, 14 of which were due to direct causes and 12 to indirect causes. The maternal mortality ratio was 8.7/100,000 live births. Fourteen of the deaths were registered in official statistics. Of the 12 deaths that were not included in the statistics, 11 were found through matching the registers and one had been reported directly by the hospital. The most common causes of death were hypertensive disorders during pregnancy (n = 6), thromboembolism (n = 4) and mental illness (n = 4). None of the deaths due to thromboembolism appeared in official statistics. The same applied to nine of the 12 indirect maternal deaths. We found a potential for improved medical care in 14 of 26 cases. Half of these were deaths due to hypertensive disorders during pregnancy or thromboembolism. INTERPRETATION: Maternal death was considerably underreported in Norwegian official statistics during the period studied. Greater attention should be given to better blood-pressure treatment, stabilisation and timely delivery in the case of hypertension during pregnancy, and to screening for possible pulmonary embolism. The same applies to mental illness and internal medical disorders in pregnant women.

Single nucleotide polymorphisms in G protein signaling pathway genes in preeclampsia.

Preeclampsia is a pregnancy specific disorder and a risk factor for later cardiovascular disease. The cause and detailed pathophysiology remains unknown. G protein signaling is involved in a variety of physiological processes, including blood pressure regulation. We assessed whether distributions of 3 single nucleotide polymorphisms in genes coding for components of G protein signaling pathways that have been associated with hypertension differ between women with preeclampsia and normotensive pregnant women; the G protein ß3 subunit gene (GNB3) C825T polymorphism (rs5443), the angiotensin II type 1 receptor gene (AGTR1) 3'UTR A1166C polymorphism (rs5186), and the regulator of G protein signaling 2 gene (RGS2) 3'UTR C1114G polymorphism (rs4606). Two separate Norwegian study populations were used; a large population based study and a smaller, but clinically well-described pregnancy biobank. A descriptive study of 43 women with eclampsia was additionally included. In the population-based study, an increased odds of preeclampsia (odds ratio, 1.21; [95% confidence interval, 1.05-1.40]; P=0.009) and recurrent preeclampsia (odds ratio, 1.43; [95% confidence interval, 1.06-1.92];, P=0.017) was found in women carrying the rs4606 CG or GG genotype. In early-onset preeclamptic patients with decidual spiral artery biopsies available (n=24), the rs4606 CG or GG genotype was more frequent in those with acute atherosis (resembling early stage of atherosclerosis) compared with those without: odds ratio, 15.0; (95% confidence interval, 2.02-111.2); P=0.004. No association was found between preeclampsia and the rs5443 or the rs5186. The genotype distribution in eclamptic women was not different from preeclamptic women. In conclusion, RGS2 rs4606 may affect the risk and progression of preeclampsia.

Follow-up interviews after eclampsia.

BACKGROUND/AIMS: The aim of the study was to assess the prevalence of persisting symptoms 6 months or more after eclampsia. METHODS: During a 2-year period (mid-1998 to mid-2000), 210 patients with eclampsia were included in a prospective cohort study of eclampsia in Denmark, Norway and Sweden. One hundred and twenty-three women (59%) were followed up with a structured telephone interview, 6-24 months (median 11) after their eclamptic fit. RESULTS: At the time of follow-up, 63 women (51%) had at least one persistent symptom; 2 patients had severe neurological sequels (hemiparesis and dysarthria), 11% had visual disturbances, 22% had problems concentrating or recalling phone numbers and messages, 18% reported frequent headaches and 10% had vertigo or balance problems. CONCLUSION: Although few women suffered from severe sequels, many women had persisting symptoms following eclampsia indicating a need for follow-up of these patients. A case-control study comparing the health and symptoms between women having suffered from eclampsia and women without this complication may therefore be justified.

Direct maternal deaths in Norway 1976-1995.

AIMS: To report direct maternal mortality ratio (MMR) in Norway between 1976 and 1995 including a description of the underlying complications in pregnancy, the causes of death and assessment of standard of care. METHODS: The maternal deaths were identified through the Cause of Death Registry, Statistics Norway, and Medical Birth Registry of Norway. We requested copies of the hospital case records and the maternal death autopsies. The direct maternal deaths were classified on the basis underlying causes and assessed for substandard care according to the guidelines at the time of death and preventability provided optimal conditions and up to date guidelines. RESULTS: In the period 1976-1995 we identified 61 direct maternal deaths in Norway. The direct MMR was 5.5/100,000 births. Sufficient information was available for analysis in 51 of these cases. Six deaths occurred in early pregnancy. Among the 45 women who gave birth, 32 had a cesarean section, and the death was judged to be related to a complication of the operation in more than half of these cases. The standard of care and the possibility of preventing death were evaluated in 49 cases. Substandard care was observed in 21 of them and 27 were considered avoidable or potentially avoidable. CONCLUSION: The direct MMR in Norway was 5.5/100,000 births. The main causes were complications of hypertensive disease of pregnancy and thromboembolism. The majority of maternal deaths were associated with cesarean delivery and considered potentially avoidable.

Eclampsia in Scandinavia: incidence, substandard care, and potentially preventable cases.

BACKGROUND: Description of incidence, clinical signs, symptoms, and consequences of eclampsia in Scandinavia, and assessment of substandard care and potential preventability. METHODS: A descriptive cohort study including all women giving birth in a 2-year period (mid-1998-mid-2000) in Scandinavia. Notifications of eclampsia cases were obtained from all obstetric units at 3-monthly intervals. All patient files were reviewed, and systematic audit was performed to identify potentially preventable cases by using predefined criteria. MAIN OUTCOME MEASURES: Signs and symptoms preceding the eclamptic seizure, the standard of medical care, maternal and perinatal morbidity, and mortality were all recorded. Potentially preventable cases through improved care and cases eligible for primary prophylactic magnesium sulfate (MgSO4) were estimated. RESULTS: The incidence of eclampsia was 5.0/10,000 maternities (CI = 4.3-5.7/10,000). Eighty-six percent had a diagnosis of pre-eclampsia before the seizure. Nine of 10 had at least one physical complaint before the first seizure, severe headache being the most common symptom, occurring in two-thirds. Most seizures (90%) occurred after admission to hospital. By audit, 89 cases (42%) were classified as having received substandard care. Prophylactic use of magnesium sulfate might have reduced the number of eclampsia cases by 35 (17%). CONCLUSIONS: Eclampsia occurred mainly in hospital and the majority of women had symptoms heralding the seizure. In retrospect, nearly half of the cases were found potentially preventable by timely intervention, improved medical care, and systematic use of prophylactic treatment with MgSO4.