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PubMed2005

Neurologic disorders in pregnancy.

BACKGROUND: Neurologic dysfunction, coma, and seizures are common in obstetric patients in the intensive care unit. OBJECTIVE: To review common neurologic disorders resulting in critical illness in pregnancy. REVIEW: Obstetric disorders causing coma and seizures include eclampsia, acute fatty liver of pregnancy, and amniotic fluid embolism. Preexisting disorders such as epilepsy may worsen in one-third of pregnant patients, and seizures are common during labor. Changes in hemodynamics, blood volume, and hormonal effects on the vessel wall increase risk of bleeding from berry aneurysms and arteriovenous malformations during pregnancy and the postpartum period. Acute intermittent porphyria produces seizures and hypertension, closely mimicking eclampsia. Cerebral venous sinus thrombosis is common in postpartum patients, especially in developing countries. Brain tumors invariably enlarge during pregnancy because of fluid retention and the presence of estrogen and progesterone receptors on tumor cells. Infections such as cerebral malaria and acute viral hepatitis with fulminant hepatic failure are common causes of coma and seizures during pregnancy in tropical regions of Asia, Africa, and Latin America. Patients may be admitted to the intensive care unit with type II respiratory failure due to myasthenic crisis, Guillain-Barre syndrome and spinal cord disease. Relapses of multiple sclerosis are infrequent during pregnancy but increase in the postpartum period. CONCLUSIONS: In all instances, the effects of the disorders, diagnostic tests, and treatment on the fetus must be carefully weighed. Prompt delivery may be lifesaving for mother and fetus in conditions such as eclampsia and acute fatty liver of pregnancy; expectant treatment may be more appropriate in others.

Critical Care↗
PubMed2005

Maternal collapse.

PURPOSE OF REVIEW: This review will summarize the latest publications on the causes, prevention and treatment of maternal collapse during pregnancy and the postpartum period. It will also explore some future trends particularly in the area of education and team working. RECENT FINDINGS: Active management of the third stage of labour has been shown to decrease the incidence of postpartum haemorrhage. Inadequate or prolonged resuscitation following major postpartum haemorrhage can lead to myocardial damage. Guidelines that are followed and the use of drills and simulators may increase effective team working and lead to earlier recognition and treatment of maternal collapse. Some cases of amniotic fluid embolism resemble anaphylaxis and should be treated as such. Important evidence-based guidelines on the management of antithrombolytic prophylaxis and the management of pulmonary embolism have recently been published, which should help clinicians clarify their medical care plans. New resuscitation guidelines in the UK will probably mean that all healthcare workers (including obstetricians and midwives) will need appropriate training every year. SUMMARY: Understanding the causes of maternal collapse, its early recognition and prompt resuscitation should decrease both maternal and fetal morbidity and mortality. There is increasing evidence that effective preventative measures and improved multidisciplinary team working may have an important impact on maternal and fetal well-being.

Embolism↗
PubMed2006

Pregnancy-associated deaths: a 15-year retrospective study and overall review of maternal pathophysiology.

Pregnancy-related death is defined by the International Classification of Diseases, Tenth Revision (ICD-10) as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. In the year 2000, a collaborative effort involving World Health Organization (WHO), UNICEF, and UNFPA estimated 660 maternal deaths in the United States. This averages 11 maternal deaths per 100,000 live births reported. Many pregnancy-associated deaths are not easily identified as such since the presence of a recent or current pregnancy may not be listed on the death certificate. Thus, the WHO estimates that in the United States, the maternal mortality is approximately 17/100,000 pregnancies. This is significantly higher than the goal set by the US Department of Health and Human Services in Healthy People 2010, which sets the target for maternal mortality at less than 3.3/100,000 live births. The most common causes of maternal death vary somewhat from region to region in the United States. They include pulmonary thromboembolism, amniotic fluid embolism, primary postpartum uterine hemorrhage, infection, and complications of hypertension including preeclampsia and eclampsia. Pulmonary disease, complications of anesthesia, and cardiomyopathy also are significant contributors to maternal mortality in some populations. The death of a pregnant or recently pregnant individual poses a wide scope of challenges to the forensic pathologist and investigator. The pathologist must have a broad knowledge of the physiologic and biochemical changes that occur during pregnancy, as well as the clinical and pathological manifestation of these changes. Conditions that may be "benign" in the nonpregnant individual may be lethal in the puerperal period. In addition, it should be kept in mind that deaths during pregnancy may be due to unnatural causes. Accident, homicide, and suicide must be ruled out in each case. The authors reviewed all forensic cases referred for autopsy to the Forensic Section of the Medical University of South Carolina from January 1989 through December 2003. All decedents listed as pregnant or postpartum were analyzed as to maternal age, race, past medical history, previous pregnancies and outcome, prenatal care, gestational age, fetal or neonatal outcome, location of delivery, placental findings, maternal autopsy findings, toxicology, cause of death, manner of death, and fetal or neonatal autopsy findings. The authors present this retrospective study to better determine the factors leading to maternal demise and discuss the autopsy/ancillary techniques useful in determining the cause of death in this challenging area.

Adult↗
PubMed1989

How safe is caesarean section in current practice? A survey of mortality and serious morbidity.

To assess the safety of Caesarean section in a tertiary referral hospital, a survey was made of maternal deaths associated with the operation in 40,958 total births during the recent 6 years (1982-1987) and serious morbidity in 1,959 consecutive operations over a recent 15-month interval (1986-1987) at the Royal Women's Hospital, Brisbane. There were only 2 deaths in 9,584 Caesarean sections, giving a maternal mortality rate of 20.8 per 100,000 operations and a risk ratio of 3.2 when compared with vaginal delivery. As both deaths were caused by amniotic fluid embolism, they were not considered to be directly attributable to the operation. Serious morbidity, as measured by operative complications, thromboembolism, need for blood transfusion, admission to the intensive care unit, and return of the patient to the operating theatre, was uncommon. The most common morbidity was postoperative pyrexia (representing infection) in 7.7% of operations; this was found to be more frequent in patients under 35 years, those in the public section and those requiring general anaesthesia.

Adult↗
PubMed1971

Permeability of membranes of dead fetus.

Membranes of dead fetuses showed a three-fold increase in permeability to the haemoglobin molecule when compared with normal and stored membranes. The friability of some of these membranes was markedly increased and their strength and elasticity diminished. These findings may be significant in the aetiology of the hypofibrinogenaemia and the increased incidence of amniotic fluid embolism with intrauterine death of the fetus.

Afibrinogenemia↗
PubMedDate not supplied

Thrombotic and nonthrombotic pulmonary arterial embolism: spectrum of imaging findings.

Along with clinical examination and laboratory tests, imaging plays a key role in the diagnosis of pulmonary embolism. Multi-detector row helical computed tomography (CT) is particularly helpful in the diagnosis of acute pulmonary thromboembolism (PTE) owing to its capacity to directly show emboli as intravascular filling defects. Although parenchymal abnormalities at CT are nonspecific for acute PTE, they may contribute to a correct diagnosis of chronic PTE, the characteristic helical CT features of which are similar to its angiographic features and include webs or bands, intimal irregularities, abrupt narrowing or complete obstruction of the pulmonary arteries, and "pouching defect." Nonthrombotic pulmonary embolism is an uncommon condition but is sometimes associated with specific imaging findings, including discrete nodules with cavitation (septic embolism), widespread homogeneous and heterogeneous areas of increased opacity or attenuation that typically appear 12-24 hours after trauma (fat embolism), and fine miliary nodules that subsequently coalesce into large areas of increased opacity or attenuation (talcosis). Knowledge of appropriate imaging methods and familiarity with the specific imaging features of pulmonary embolism should facilitate prompt, effective diagnosis.

Adult↗
PubMed1995

Incidence and causes of strokes associated with pregnancy and puerperium. A study in public hospitals of Ile de France. Stroke in Pregnancy Study Group.

BACKGROUND AND PURPOSE: The incidence, causes, and prognosis of nonhemorrhagic strokes and intraparenchymal hemorrhages occurring in association with pregnancy or puerperium are poorly understood. METHODS: We carried out a retrospective (1989 through 1991) and prospective (1992) study in 63 public maternities (348,295 deliveries) of the region of Ile de France (10,660,554 inhabitants) and in the neurology, neurosurgery, and intensive care units of the same geographic area. Records of women who suffered a cerebrovascular event during pregnancy or the first 2 weeks postpartum were reviewed by two study neurologists. Stroke was defined according to the criteria of the World Health Organization. RESULTS: Thirty-one cases of strokes were identified, including 15 nonhemorrhagic strokes (including strokelike deficits associated with eclampsia) and 16 intraparenchymal hemorrhages, assessed in all cases by CT scan and/or MRI. The incidence of nonhemorrhagic strokes in women who delivered in public maternities of Ile de France was 4.3 per 100,000 deliveries (95% confidence interval, 2.4 to 7.1) and that of intraparenchymal hemorrhage was 4.6 per 100,000 deliveries (95% confidence interval, 2.6 to 7.5). Eclampsia accounted for 47% of cases of nonhemorrhagic strokes. The other causes were extracranial vertebral artery dissection, postpartum cerebral angiopathy, inherited protein S deficiency, and disseminated intravascular coagulation associated with amniotic fluid embolism. The cause remained undetermined in four cases despite extensive investigations. Eclampsia accounted for 44% of intraparenchymal hemorrhages. Another 37% were due to rupture of a vascular malformation. The cause remained undetermined in three cases. There were four maternal deaths (all associated with intraparenchymal hemorrhage), three of them in eclamptic women. Fetal mortality and prematurity were associated with eclampsia. CONCLUSIONS: The incidence of nonhemorrhagic stroke does not seem to be much increased during pregnancy and early puerperium. In contrast to that in the nonpregnant state, the frequency of intraparenchymal hemorrhage in pregnancy appears to be similar to that of nonhemorrhagic strokes, suggesting that pregnancy may increase the risk of cerebral hemorrhage. Eclampsia is the main cause of both nonhemorrhagic stroke and intraparenchymal hemorrhage. Intraparenchymal hemorrhage associated with eclampsia carries a poor prognosis.

Adult↗
PubMed2006

Trauma in pregnancy: assessment and treatment.

Women between the ages of 10 and 50 year-old have the potential for pregnancy; therefore this condition must be taken into consideration when a woman is examined in the Emergency Room after sustaining a traumatic event. Pregnancy produces significant physiologic and anatomic changes in every system of the female body. The evaluation of the traumatized pregnant patient, the approach, and the interpretation of the diagnostic tests results must be accompanied by the full knowledge of all changes that take place during pregnancy. In the same context, although the physician treating a pregnant trauma victim must remember that there are two patients, the treatment priorities are the same as for the non-pregnant trauma patient. The best initial treatment for the fetus is the optimum resuscitation of the mother. A thorough exam should take place to discover unique conditions that might be present in any pregnant patient such as blunt or penetrating injury to the uterus, placental abruption, amniotic fluid embolism, isoimmunization, and premature rupture of membranes. The obstetrician should be present at all times and be considered a part of the trauma team in the evaluation and treatment of a pregnant trauma patient.

Adolescent↗
PubMed1986

Maternal deaths in Sweden, 1971-1980.

Sixty-eight deaths during pregnancy, parturition and puerperium were recorded in Sweden during the years 1971-80, giving a maternal mortality of 6.6 per 100,000 live births. The figures for abdominal delivery and vaginal were 45.0 and 2.5 per 100,000 live births respectively. Amniotic fluid embolism, pulmonary embolism and hemorrhage were the main causes of death within 24 hours after delivery, while pre-eclampsia/eclampsia and sepsis were predominant during the rest of the puerperium. Age and parity are highly important risk factors. Presumed avoidable factors were identified in 19% of the cases. 9% of the deaths were related to unwanted pregnancy.

Abortion, Septic↗
PubMed2000

[The complication of multiple system organs failure in pregnancy: a clinical analysis of 13 cases].

OBJECTIVE: To find out the features and causes of the complications of multiple system organs failure (MSOF) in pregnancy and increase the level of its prevention and treatment. METHODS: A retrospective study was carried out on 13 cases with the complication of MSOF in pregnancy admitted between Feb 1992-Jun 1999. RESULTS: There were two or more organs or systems function failure in the pregnancy. Four cases induced by infection, 5 cases induced by heart diseases, 3 cases induced by pregnancy induced hypertension, 1 case induced by amniotic fluid embolism. 12 of 13 were cured. 1 was died. Among them one infant was died. CONCLUSIONS: During the treatment of pregnancy with multiple system organs failure, it is important to control the causes and inducements. It is forcible to terminate pregnancy in time and choose a best style of delivery. It is better to keep watch on saving multiple system organs function.

Adult↗
PubMed1999

"Near miss" obstetric morbidity in an inner city hospital in Saudi Arabia.

A defined "near-miss" end-point, e.g. peripartum hysterectomy, is a more useful measure of obstetric care in a modern inner-city hospital than maternal mortality. Thus, indication(s), type of operation, risk factors and surgical morbidity of all cases of peripartum hysterectomy conducted over a period of 85 months at King Abdul Aziz Hospital, Jeddah were reviewed. The incidence of hysterectomy was 1.22 per 1000 deliveries. Atonic postpartum haemorrhage was the most common reason (43.5%), followed by ruptured uterus (30.4%) and placenta accreta (26.1%). Of the atonic group, five patients were primigravidae, three of whom had severe pre-eclampsia. Abnormally prolonged labour was noted in this group. In the uterine rupture group, only two patients had had previous caesarean sections. In the placenta accreta group, three patients had placenta praevia, two of whom had scars from previous caesarean sections. One maternal death was attributed to amniotic fluid embolism.

Adult↗
PubMed1999

[Analysis of national maternal mortality rate surveillance. Maternal Death Investigation Cooperative Group of China].

OBJECTIVE: To analyze the results of maternal mortality rate (MMR) surveillance in 247 monitoring areas. METHODS: Based on the demographic characteristics of different areas, stratum sampling method was used, and 247 monitoring points from 30 provinces, autonomous regions and cities covered about 100 million population were selected in China in 1989-1995. RESULTS: In the 7 years of monitoring there were 8,709,220 cases of live births with 5,984 cases of maternal deaths in these monitoring points. The average MMR was 77.4/100,000 with 45.5/100,000 in urban areas and 95.4/100,000 in rural areas. There were significant differences of MMR from area to area from 26.0/100,000 to 308.0/100,000. The causes of maternal deaths in succession were obstetric hemorrhage, pregnancy induced hypertension, heart diseases, amniotic fluid embolism, puerperal infection and hepatic diseases, and these 6 causes constituted 81.6% of the total. According to the audit of mortality cases demanded by WHO, the results showed that there was 73.0% avoidable deaths and 27.0% unavoidable deaths. The main problems were: 49.7% among the medical and health care system, chiefly lack of knowledge and skill of the medical personnels; 44.5% of the pregnant women and their family members lack the basic health knowledge. CONCLUSION: To improve the living condition of both mother and children, to increase hospital delivery rate, training medical personnel's skill, to provide better maternal health care, and to strengthen health education are effective measures to decrease MMR.

Cause of Death↗
PubMed1975

Disseminated intravascular coagulation in gynecologic cancer.

Disturbances in the blood coagulation mechanism are seen by the obstetrician and gynecologist as rare complications of abruptio placentae, retained dead fetus syndrome, amniotic fluid embolism, toxemia, saline amnioinfusion, and septic abortion. Two cases of disseminated intravascular coagulation complicating gynecologic malignancy are presented. Laboratory studies showed thrombocytopenia, hypofibrinogenemia, and increased fibrin degradation products. Derangements of hemostasis in patients with malignancy are discussed from a clinical viewpoint.

Blood Coagulation Tests↗
PubMed2003

Anaphylactoid syndrome of pregnancy: a review of the literature with latest management and outcome data.

This article is a review of information on the subject of anaphylactoid syndrome of pregnancy or amniotic fluid embolism, as it is more commonly known. Information was found through a computer search of English articles published from 1958 to 2001. Anaphylactoid syndrome of pregnancy has an 80% to 90% mortality rate. It is difficult to diagnose, and once symptoms occur, there is a rapid deterioration in the patient's condition. It has severe manifestations such as shock and coagulopathy. Identification of the exact mechanism and pathophysiology that trigger the syndrome continue to be investigated. Recognition of the event, swift and aggressive treatment, and education of those who provide care in the obstetrical setting give promise of greater survival potential. Although mortality remains high, there are reports of survivors.

Anaphylaxis↗
PubMed2002

The diagnosis and management of disseminated intravascular coagulation.

This review describes disseminated intravascular coagulation (DIC) as a syndrome in which hemostatic factors are activated. The syndrome ranges in severity from a decompensated coagulopathy (overt-DIC) to the subclinical compensated activation of hemostatic factors (nonovert DIC). The first part of this review emphasizes two points. First, activation of the hemostatic system is controlled by a vast network of capillaries and venules through anticoagulant and anti-inflammatory regulatory factors that operate from the endothelium (e.g., protein C and thrombomodulin, tissue factor pathway inhibitor). These hemostatic regulators can be overridden by procoagulant disorders such as amniotic fluid embolism or degraded by proinflammatory disorders such as sepsis. Second, because this link between the microvascular endothelium and circulating hemostatic factors is so close, even a relatively mild disturbance of the microvasculature targeted by the inflammatory process may be reflected systemically by changes in molecular biomarkers of hemostatic activity. Therefore, application of criteria for the diagnosis of nonovert DIC should be of value in detecting a compensated response to inflammatory stress of the microvasculature in patients who are at risk before they develop an uncompensated over DIC response and organ failure. The second part of this review covers the recent experience investigators have had in diagnosing and following the response of patients to treatment with biomarkers.

Biomarkers↗
PubMedDate not supplied

Relevance of plasma fibrinogen estimation in obstetric complications.

We present a study of fibrinogen levels in 133 patients who were prone to develop disseminated intravascular coagulation as a result of an underlying complication of pregnancy such as abruptio placentae, pregnancy-induced hypertension, missed abortion, septic abortion, intrauterine fetal death, vesicular mole and amniotic fluid embolism. A high incidence of hypofibrinogenemia was found in cases of abruptio placentae (43.9%) and pregnancy-induced hypertension (25%). Hypofibrinogenemia occurred in 10% cases of intrauterine fetal death within 4 weeks of fetal demise. The use of this simple investigation makes possible the diagnosis of hemostatic failure and also helps to guide replacement therapy during the fibrinopenic state. There were 4 maternal deaths and 12 perinatal losses in this study.

Abruptio Placentae↗