Causes of maternal death at Natalspruit Hospital, Johannesburg, South Africa.

BACKGROUND: Despite increased resources to reduce maternal deaths, South Africa (SA) has an unacceptably high maternal mortality rate (MMR). OBJECTIVES: To determine the causes of maternal deaths at Natalspruit Hospital, Johannesburg, SA. METHODS: A 2-year retrospective audit of case records was done All maternal deaths from January 2013 to December 2014 were included. RESULTS: There were 20 676 live births and 79 deaths, with a MMR of 382.08/100 000. Forty-four women (56%) were HIV-positive, 14 (21%) died of obstetric haemorrhage and 12 (15%) had hypertensive disorders of pregnancy. Thirty women (38%) had not attended an antenatal clinic. More women died between 16h00 and 08h00 than between 08h00 and 16h00. Most women (88%) had at least one avoidable factor. CONCLUSIONS: Natalspruit Hospital has a high MMR. The majority of deaths were HIV-related. There was a high number of women who were unbooked. Most deaths occurred after normal working hours.

Embarazo ectópico intraligamentario / Ectopic Intraligamentary Pregnancy

Introducción: El embarazo ectópico es la implantación del producto de la concepción fuera de la cavidad endometrial. Objetivo: Reportar un caso de embarazo ectópico intraligamentario por lo infrecuente que es esta localización. Métodos: Presentación de caso de paciente de 25 años, con antecedentes de VIH e infecciones vaginales a repetición. Asiste a emergencias con dolor intenso en bajo vientre e historia de amenorrea de 12 semanas. Se hace el diagnóstico de posible embarazo ectópico abdominal y se decide laparotomía de urgencia. Resultados: Durante el transoperatorio se diagnostica un embarazo ectópico intraligamentario izquierdo, se realiza salpingectomía con resección de todo el ligamento ancho. La paciente evolucionó satisfactoriamente. Conclusiones: El embarazo ectópico continúa siendo una de las principales urgencias dentro de las especialidades quirúrgicas. Sigue elevando la mortalidad materna a nivel mundial y siempre que las condiciones lo permitan se debe pensar en él para hacer un diagnóstico oportuno(AU)

Introduction: Ectopic pregnancy is the implantation of the product of conception outside the endometrial cavity. Objective: To report a case of intraligamentary ectopic pregnancy because of the infrequent nature of this location. Case Report: This is a 25-year-old patient with a history of HIV and repeated vaginal infections. She comes to the emergency room with severe pain in the lower abdomen and history of amenorrhea for 12 weeks. Possible abdominal ectopic pregnancy is diagnosed and the emergency laparotomy is decided. During the transoperative period, a left intraligamentary ectopic pregnancy was diagnosed. Salpingectomy was performed with resection of the entire broad ligament. Result: The patient evolved satisfactorily. Conclusions: Ectopic pregnancy continues to be one of the main emergencies in surgical specialties. Maternal mortality continues raising worldwide and whenever the conditions suggest so, we must think about it to make a timely diagnosis(AU)

Non-surgical treatment of ectopic pregnancy

In the past few decades, ectopic pregnancy has been termed by medical practitioners has a global epidemic. With the questions lingering on everbody minds how this menace can be tamed. In a bid to reduce the mortality and financial burden brought by this evolving growing health concern, the medic has developed non-surgical alteratives to deal with ectopic pregnancy, i.e., treatment using methotrexate. In a bid to explore this topic further, these study goals were to share the experience of treating mothers who have un-ruptured ectopic pregnancies traditionally. Mothers who were found to have an ectopic pregnancy and fit the medical care were encompassed in the program, a total of 37 women. For instance, those with serum beta HCG in the range of 1000 mIU per liter were treatment expectantly whereas those with a level more than a thousand were given an injection of methotrexate. To monitor the response of experiment, beta HCG levels were monitored for each mother. The results of the current study established that 88.0% of women who underwent the study, only 12.0% of them exhibited full rsolution while the remaining lot resolved only after a sole dose of methotrexate. From the results of this study, it is evidently clear that a lot of pregnant mothers would be greatly helped if they are enrolled in such therapy at early days

Temporal trends in severe morbidity and mortality associated with ectopic pregnancy requiring hospitalisation in Washington State, USA: a population-based study.

OBJECTIVE: To examine temporal trend in maternal mortality/severe morbidity associated with hospitalisation due to ectopic pregnancy. DESIGN: A population-based observational study. SETTING AND PARTICIPANTS: All women hospitalised for ectopic pregnancy in Washington State, USA, 1987-2014 (n=20 418). The main composite outcome of severe morbidity/mortality included death, sepsis, need for transfusion, hysterectomy and systemic or organ failure, identified by diagnostic and procedure codes from hospitalisation files. Severe morbidity/mortality due to ectopic pregnancy were expressed as incidence ratios among women of reproductive age (15-64 years) and among women hospitalised for ectopic pregnancy. Comparisons were made between 1987-1991 (reference) and 2010-2014 using ratios of incidence ratios (RR) and ratio differences (RD). The Cochran-Armitage test for trend assessed statistical significance; logistic regression was used to obtain adjusted OR (AOR) and 95% CI, adjusted for demographic factors and comorbidity. RESULTS: Hospitalisation for ectopic pregnancy declined from 0.89 to 0.16 per 1000 reproductive age women between 1987-1991 and 2010-2014 (p<0.001). Among reproductive age women, ectopic pregnancy mortality remained stable (0.03 per 100 000); and mortality/severe morbidity increased among women aged 25-34 years (p=0.022). Among women hospitalised for ectopic pregnancy, mortality increased from 0.29 to 1.65 per 1000 between 1987-1991 and 2010-2015 (p=0.06); severe morbidity/mortality increased from 3.85% to 19.63% (RR=5.10, 95% CI 4.36 to 5.98; RD=15.78 per 100 women, 95% CI 13.90 to 17.66; AOR for 1-year change was 1.08, 95% CI 1.07 to 1.08). CONCLUSIONS: Hospitalisation for ectopic pregnancy declined in Washington State, USA, between 1987 and 2014; however, mortality/severe morbidity associated with ectopic pregnancy increased in female population aged 25-34 years.

Fatal ruptured ectopic pregnancy - a case report.

A 26-year-old unmarried female with a history of acute abdominal pain and bleeding per vagina was brought unresponsive to the hospital. She was in shock on arrival and could not be resuscitated. Death was registered as a medico-legal case. Further investigation by the police revealed that she had amenorrhoea for eight weeks and had tested positive for pregnancy. She had consumed abortion pills purchased from a local pharmacist without consulting a doctor and had developed acute abdominal pain after 48 h. Autopsy revealed a ruptured ectopic pregnancy (tubal type).

Institutional maternal and perinatal deaths: a review of 40 low and middle income countries.

BACKGROUND: Understanding the magnitude and clinical causes of maternal and perinatal mortality are basic requirements for positive change. Facility-based information offers a contextualized resource for clinical and organizational quality improvement. We describe the magnitude of institutional maternal mortality, causes of death and cause-specific case fatality rates, as well as stillbirth and pre-discharge neonatal death rates. METHODS: This paper draws on secondary data from 40 low and middle income countries that conducted emergency obstetric and newborn care assessments over the last 10 years. We reviewed 6.5 million deliveries, surveyed in 15,411 facilities. Most of the data were extracted from reports and aggregated with excel. RESULTS: Hemorrhage and hypertensive diseases contributed to about one third of institutional maternal deaths and indirect causes contributed another third (given the overrepresentation of sub-Saharan African countries with large proportions of indirect causes). The most lethal obstetric complication, across all regions, was ruptured uterus, followed by sepsis in Latin America and the Caribbean and sub-Saharan Africa. Stillbirth rates exceeded pre-discharge neonatal death rates in nearly all countries, possibly because women and their newborns were discharged soon after birth. CONCLUSIONS: To a large extent, facility-based findings mirror what population-based systematic reviews have also documented. As coverage of a skilled attendant at birth increases, proportionally more deaths will occur in facilities, making improvements in record-keeping and health management information systems, especially for stillbirths and early neonatal deaths, all the more critical.

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.

Abnormal implantation after fresh and frozen in vitro fertilization cycles.

OBJECTIVE: To determine whether fresh embryo transfers are at a higher risk of abnormal implantation compared with frozen embryo transfers while accounting for the embryo stage at transfer. DESIGN: Retrospective cohort study. SETTING: Not applicable. PATIENT(S): We used data from the Society for Assisted Reproductive Technologies to identify all fresh and frozen autologous IVF cycles from 2004-2013 resulting in a positive pregnancy test. The cycles were parameterized into a four-level predictor of [1] fresh blastocyst transfer, [2] fresh non-blastocyst transfer, [3] frozen blastocyst transfer, and [4] frozen non-blastocyst transfer. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): We examined a composite outcome of abnormal implantation, defined as biochemical pregnancy, ectopic/heterotopic pregnancy, and first-trimester pregnancy loss. Regression modeling was performed with repeated measures multivariable logistic regression, adjusted for age, parity, number of embryos transferred, infertility diagnosis, and calendar year of treatment. RESULT(S): Of 509,938 cycles analyzed, 31.8% resulted in abnormal implantation. Compared with a fresh blastocyst transfer, a fresh non-blastocyst transfer had a 22% increase risk of abnormal implantation, a frozen blastocyst transfer had a 36% increase risk, and a frozen non-blastocyst transfer had a 57% increase risk. When individual outcomes were analyzed, fresh embryo transfers had a lower risk of biochemical pregnancy and pregnancy loss but a higher risk for ectopic/heterotopic pregnancy. CONCLUSION(S): Fresh blastocyst transfers had the lowest overall risk of abnormal implantation but a higher risk of ectopic/heterotopic pregnancy. Although embryo cryopreservation is indicated in certain treatment cycles, elective embryo cryopreservation may not be the optimal strategy to adopt for all cycles.

The triple threat of pregnancy, HIV infection and malaria: reported causes of maternal mortality in two nationwide health facility assessments in Mozambique, 2007 and 2012.

BACKGROUND: The paper's primary purpose is to determine changes in magnitude and causes of institutional maternal mortality in Mozambique. We also describe shifts in the location of institutional deaths and changes in availability of prevention and treatment measures for malaria and HIV infection. METHODS: Two national cross-sectional assessments of health facilities with childbirth services were conducted in 2007 and 2012. Each collected retrospective data on deliveries and maternal deaths and their causes. In 2007, 2,199 cases of maternal deaths were documented over a 12 month period; in 2012, 459 cases were identified over a three month period. In 2007, data collection also included reviews of maternal deaths when records were available (n = 712). RESULTS: Institutional maternal mortality declined from 541 to 284/100,000 births from 2007 to 2012. The rate of decline among women dying of direct causes was 66% compared to 26% among women dying of indirect causes. Cause-specific mortality ratios fell for all direct causes. Patterns among indirect causes were less conclusive given differences in cause-of-death recording. In absolute numbers, the combination of antepartum and postpartum hemorrhage was the leading direct cause of death each year and HIV and malaria the main non-obstetric causes. Based on maternal death reviews, evidence of HIV infection, malaria or anemia was found in more than 40% of maternal deaths due to abortion, ectopic pregnancy and sepsis. Almost half (49%) of all institutional maternal deaths took place in the largest hospitals in 2007 while in 2012, only 24% occurred in these hospitals. The availability of antiretrovirals and antimalarials increased in all types of facilities, but increases were most dramatic in health centers. CONCLUSIONS: The rate at which women died of direct causes in Mozambique's health facilities appears to have declined significantly. Despite a clear improvement in access to antiretrovirals and antimalarials, especially at lower levels of health care, malaria, HIV, and anemia continue to exact a heavy toll on child-bearing women. Going forward, efforts to end preventable maternal and newborn deaths must maximize the use of antenatal care that includes integrated preventive/treatment options for HIV infection, malaria and anemia.

El embarazo ectópico sigue siendo un problema no resuelto / Ectopic pregnancy is still an unsolved problem

El embarazo ectópico (EE) juega un papel importante en la mortalidad materna en Cuba, y su incidencia está aumentando tanto en nuestro país como a escala internacional. Se realizó análisis de los datos relacionados con las muertes maternas ocurridas en Cuba entre los años 2004-2013, según el estudio y la discusión realizados por la Comisión Nacional de Mortalidad Materna (MM) del MINSAP con el objetivo de actualizar los conocimientos sobre el diagnóstico y el tratamiento oportuno de esta entidad. Se presenta el significativo porcentaje que el EE ha tenido en la mortalidad materna durante el decenio, desglosando por provincias y en los sitios en que han ocurrido las fallecidas. Se concluye que el diagnóstico y el tratamiento oportuno del EE pueden contribuir a la disminución de la mortalidad materna(AU)

Ectopic pregnancy plays an important role in maternal mortality in Cuba, and its incidence is increasing in our country and worldwide. Analysis of data related to maternal deaths in Cuba between 2004-2013 was performed according to the study and discussion carried out by the National Commission on Maternal Mortality (MM) of the Ministry of Public Health with the aim of updating the knowledge about diagnosis and timely treatment of this entity. The significant percentages that the EP has had in maternal mortality over the decade is presented here with a breakdown by province and in the places where dead has occurred. It is concluded that timely diagnosis and treatment of the EP can contribute to the reduction of maternal mortality(AU)

[Main causes of maternal mortality in Mexicali, Baja California (Mexico)]. / Principales causas de mortalidad materna en Mexicali, Baja California.

OBJECTIVE: The objective of this study is to determine the main causes of maternal mortality in the period 2009 to 2013 in Mexicali, Baja California, Mexico. MATERIAL AND METHODS: Epidemiological, observational, descriptive, cross-sectional, and retrospective study was conducted with a universe of 30 cases of maternal death. The information was collected from death certificates and records of cases obtained from the Institute of State Public Service Health of University Xochicalco. RESULTS: The average age of patients were 26.6 ± 5.6 years. Educational level and marital status was with junior school 15 (50%) and free union 12 (40%) respectively, 21 (70%) had no prenatal care. The mean gestational age was 28.8 ± 3.72 weeks, there was no difference in the place of residence, urban and rural, 15(50%). The main cause of death was hemorrhage 9(30%). The highest mortality was during the postpartum period 23 (77%). During the study period, the mortality rate was 36.8 x 100,000 live births. CONCLUSIONS: The increased frequency of maternal mortality was in young women, 70% had no prenatal care. Bleeding from ectopic pregnancy was the leading cause of death.

A five year review of ectopic pregnancy at Federal Medical Centre, Owerri, South East, Nigeria.

BACKGROUND: Ectopic pregnancy remains a leading cause of maternal morbidity and mortality in the first trimester of pregnancy in developing countries. OBJECTIVES: To determine the incidence, pattern of presentation and management of ectopic pregnancies at Federal Medical Centre (FMC) Owerri. METHODS: This was a retrospective descriptive study of all cases of ectopic gestations managed at FMC Owerri between 1st January 2009 and 31st December, 2013. The case notes were retrieved from the hospital's Records Department and information on socio-demographic characteristics, age, and parity, clinical presentation, findings at laparotomy, estimated blood loss and the need for blood transfusion were obtained. Data were entered into SPSS 17.0 and analysed descriptively. RESULTS: There were 382 cases of ectopic gestations out of the total 9880 total deliveries within the study period. The incidence of ectopic pregnancy was 38.66 per 1,000 live births or I in 26 deliveries. Nulliparous women were 132 (34.5%). At presentation, 99.47% of patients had rupture with haemoperitoneum, with the commonest site being the ampulla of the fallopian tube as seen in 338 (88.4%). Salpingectomy was done in majority of cases, accounting for 355 (93%), while 248 (65%) had blood transfusion. Five (1.3%) maternal deaths occurred during period of study. CONCLUSION: Ectopic pregnancy presents a major public health challenge among women of reproductive age groups in Nigeria. Efforts should be directed to public awareness on sex education, contraception, prevention and treatment of common risk factors for ectopic pregnancy.

[Early diagnosis of ectopic pregnancy]. / A méhen kívüli fogamzás korai diagnosztikája.

Ectopic pregnancy is a high-risk condition that occurs in 2% of reported pregnancies. This percentage is fivefold higher than that registered in the 1970s. Since 1970 there has been a two-fold increase in the ratio of ectopic pregnancies to all reported pregnancies in Hungary and in 2012 7.4 ectopic pregnancies per thousand registered pregnancies were reported. Recently, the majority (80%) of cases can be diagnosed in early stage, and the related mortality objectively decreased in the past few decades to 3.8/10,000 ectopic pregnancies. If a woman with positive pregnancy test has abdominal pain and/or vaginal bleeding the physician should perform a work-up to safely exclude the possibility of ectopic pregnancy. The basis of diagnosis is ultrasonography, especially vaginal ultrasound examination and measurement of the ß-subunit of human chorionic gonadotropin. The ultrasound diagnosis is based on the visualization of an ectopic mass rather than the inability to visualize an intrauterine pregnancy. In some questionable cases the diagnostic uterine curettage or laparoscopy may be useful. The actuality of this topic is justified by practical difficulties in obtaining correct diagnosis, especially in the early gestational time.

Awareness about a life-threatening condition: ectopic pregnancy in a network for surveillance of severe maternal morbidity in Brazil.

OBJECTIVE: To assess occurrence of severe maternal complications associated with ectopic pregnancy (EP). METHOD: A multicenter cross-sectional study was conducted, with prospective surveillance of potentially life-threatening conditions (PLTC), maternal near miss (MNM), and maternal death (MD). EP complications, patient sociodemographic/obstetric characteristics, and conditions of severity management were assessed, estimating prevalence ratios with respective 95% CI. Factors independently associated with greater severity were identified using multiple regression analysis. RESULTS: Of the 9.555 severe maternal morbidity patients, 312 women (3.3%) had complications after EP: 286 (91.7%) PLTC, 25 (8.0%) MNM, and 1 (0.3%) MD. Severe maternal outcome ratio (SMOR) was 0.3/1000 LB among EP cases and 10.8/1000 LB among other causes. Complicated EP patients faced a higher risk of blood transfusion, laparotomy, and lower risk of ICU admission and prolonged hospitalization than women developing complications resulting from other causes. Substandard care was the most common in more severe maternal morbidity and EP cases (22.7% MNM and MD versus 15% PLTC), although not significant. CONCLUSION: Increased maternal morbidity due to EP raised awareness about the condition and its impact on female reproductive life. No important risk factors for greater severity were identified. Care providers should develop specific guidelines and interventions to prevent severe maternal morbidity.

The Lin28/Let-7 system in early human embryonic tissue and ectopic pregnancy.

Our objective was to determine the expression of the elements of the Lin28/Let-7 system, and related microRNAs (miRNAs), in early stages of human placentation and ectopic pregnancy, as a means to assess the potential role of this molecular hub in the pathogenesis of ectopic gestation. Seventeen patients suffering from tubal ectopic pregnancy (cases) and forty-three women with normal on-going gestation that desired voluntary termination of pregnancy (VTOP; controls) were recruited for the study. Embryonic tissues were subjected to RNA extraction and quantitative PCR analyses for LIN28B, Let-7a, miR-132, miR-145 and mir-323-3p were performed. Our results demonstrate that the expression of LIN28B mRNA was barely detectable in embryonic tissue from early stages of gestation and sharply increased thereafter to plateau between gestational weeks 7-9. In contrast, expression levels of Let-7, mir-132 and mir-145 were high in embryonic tissue from early gestations (≤ 6-weeks) and abruptly declined thereafter, especially for Let-7. Opposite trends were detected for mir-323-3p. Embryonic expression of LIN28B mRNA was higher in early stages (≤ 6-weeks) of ectopic pregnancy than in normal gestation. In contrast, Let-7a expression was significantly lower in early ectopic pregnancies, while miR-132 and miR-145 levels were not altered. Expression of mir-323-3p was also suppressed in ectopic embryonic tissue. We are the first to document reciprocal changes in the expression profiles of the gene encoding the RNA-binding protein, LIN28B, and the related miRNAs, Let-7a, mir-132 and mir-145, in early stages of human placentation. This finding suggests the potential involvement of LIN28B/Let-7 (de)regulated pathways in the pathophysiology of ectopic pregnancy in humans.

Pregnancy related causes of deaths in Ghana: a 5-year retrospective study.

OBJECTIVE: Data on maternal mortality varies by region and data source. Accurate local-level data are essential to appreciate its burden. This study uses autopsy results to assess maternal mortality causes in southern Ghana. METHODS: Autopsy log books of the Department of Pathology, Korle-Bu Teaching Hospital Mortuary were reviewed from 2004 through 2008 for pregnancy related deaths. Data were entered into a database and analyzed using SPSS statistical software (Version 19). RESULTS: Of 5,247 deaths among women aged 15-49, 12.1% (634) were pregnancy-related. Eighty one percent of pregnancy-related deaths (517) occurred in the community or within 24 hours of admission to a health facility and 18.5% (117) occurred in a health facility. Out of 634 pregnancy-related deaths, 79.5% (504) resulted from direct obstetric causes, including: haemorrhage (21.8%), abortion (20.8%), hypertensive disorders (19.4%), ectopic gestation (8.7%), uterine rupture (4.3%) and genital tract sepsis (2.5%). The remaining 20.5% (130) resulted from indirect obstetric causes, including: infections outside the genital tract, (9.2%), anemia (2.8%), sickle cell disease (2.7%), pulmonary embolism (1.9%) and disseminated intravascular coagulation (1.3%). The top five causes of maternal death were: haemorrhage (21.8%), abortion (20.7%), hypertensive disorders (19.4%), infections (9.1%) and ectopic gestation (8.7%). CONCLUSION: Ghana continues to have persistently high levels of preventable causes of maternal deaths. Community based studies, on maternal mortality are urgently needed in Ghana, since our autopsy studies indicates that 81% of deaths recorded in this study occurred in the community or within 24 hours of admission to a health facility.

Early pregnancy failure: beware of the pitfalls of modern management.

The evolution of the diagnosis and management of women with an early pregnancy loss has been a success story. The mortality from ectopic pregnancy has objectively been decreased in the past few decades. However, modern management has resulted in a new set of issues. Over-interpretation of a single ultrasound, misunderstanding of the utility of serial hCG values, and inappropriate use of methotrexate can result in iatrogenic complications. Modern management has successfully improved the diagnosis of ectopic pregnancy before rupture; it should now also focus on ensuring that an intrauterine pregnancy is not interrupted as a result of diagnosis and treatment. This article reviews some of the pitfalls of the modern management of early pregnancy failure and introduces a series of articles on the subject.