WHY MOTHER'S DIE
?MBRRACE-UK - Saving Lives, Improving Mothers’ Care 2016
Overall there was no statistically significant decrease in the maternal death rate in the UK between 2009-11 and 2012-14.Maternal deaths from direct causes remain unchanged with no significant change in the rates between 2009-11 and 2012-14.
Thrombosis and thromboembolism remain the leading cause of direct maternal death and cardiovascular disease the leading cause of indirect maternal death during or up to six weeks after the end of pregnancy.
Abstract from PubMed: “In the triennium 2006-2008, 261 women in the UK died directly or indirectly related to pregnancy. Direct deaths decreased from 6.24 per 100,000 maternities in 2003-2005 to 4.67 per 100,000 maternities in 2006–2008. This decline is predominantly due to the reduction in deaths from thromboembolism and, to a lesser extent, hemorrhage. Despite a decline in the overall UK maternal mortality rate, there has been an increase in deaths related to genital tract sepsis, particularly from community acquired Group A streptococcal disease. The mortality rate related to sepsis increased from 0.85 deaths per 100,000 maternities in 2003-2005 to 1.13 deaths in 2006-2008, and sepsis is one the most common cause of Direct maternal death.
Chorioamnionitis is a common complication of pregnancy associated with significant maternal, perinatal, and long-term adverse outcomes. Adverse maternal outcomes include postpartum infections and sepsis while adverse infant outcomes include stillbirth, premature birth, neonatal sepsis, chronic lung disease and brain injury leading to cerebral palsy and other neurodevelopmental disabilities.
Chorioamnionitis or intra-amniotic infection is an acute inflammation of the membranes and chorion of the placenta, typically due to ascending polymicrobial bacterial infection when membranes are ruptured. It can occur with intact membranes also.Clinical signs suggestive of sepsis include one or more of the following: pyrexia, hypothermia, tachycardia, tachypnea, hypoxia, hypotension, oliguria, impaired consciousness and failure to respond to treatment. These signs, including pyrexia, may not always be present and are not necessarily related to the severity of sepsis. Regular observations of all vital signs (including temperature, pulse rate, blood pressure and respiratory rate) should be recorded on a Modified Early Obstetric Warning Score (MEOWS) chart. Treatment should be started within 1 hour to reduce the risk of maternal and fetal complications. Early delivery along with antibiotics and supportive therapy is the treatment of choice.
An Interventional study was done to compare two groups of antibiotics in which allocation was Randomized/Double blinded. It is a Parallel study in which two groups of antibiotics were studied (Comparison of Ampicillin / Sulbactam vs. Ampicillin / Gentamicin) and the primary purpose was treatment. Baseline maternal and obstetric characteristics were similar between groups, including BMI, public insurance, gestational age, duration of membrane rupture, GBS status, and epidural use.Patients who met inclusion criteria were approached upon admission to Labor and Delivery. A study staff member described the study and offered participation. Those who agreed to participate, signed research protocol and consent forms. When the participating patients started to have signs & symptoms of chorioamnionitis, they were randomized in a blinded fashion to Arm1(ampicillin/sulbactam) or Arm2(ampicillin/gentamicin).
For literate women, the consent information was provided followed by providing a copy of the consent form that each participant was required to sign to signify her consent. For non-literate women, the consent information sheet was read in full and participants required to place a thumb print on the consent form to signify their acceptance to participate in the study. A nurse or doctor who was not part of the study was around to witness and verify the counseling process for illiterate women. Participation was voluntary and those declining to participate were still entitled to the standard care provided to all women in the labor ward. AS and AG antibiotic regimens appear equally effective for treatment of intrapartum chorioamnionitis. However, there was a decrease in postpartum morbidity associated with use of AS.
Message: Be vigilant/ Use of MEOWS Chart, Early diagnosis, Prompt Treatment, Multi- Disciplinary approach, Follow-up, Psychological support and Advice for subsequent pregnancy.
Acknowledgement:
MBRRACE-UK - Saving Lives, Improving Mothers’ Care 2016
Pub Med
Clinicalgov.org.
RCOG Guidelines.