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Maternal Mortality and Hemorrhage PowerPoint Presentation

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Tags : Obstetrics, Gynecology, Maternal Mortality, Hemorrhage

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Slide 1-

Maternal Mortality and Hemorrhage Gina M. Brown, MD NYC Department of Health and Mental Hygiene Bureau of Maternal, Infant and Reproductive Health
Slide 2-

Special Thanks to: Candace Mulready, MPH Katrina Manzano, MPH Vani Bettegowda, MHS Office of Vital Statistics Office of the City Medical Examiner SPARCS Bureau of Maternal, Infant and Reproductive Health
Slide 3-

Maternal Mortality Ratio Deaths/100,000 live births during pregnancy or within 1 year of termination. A ratio not a rate: cannot count total # pregnancies Pregnancy Related OB complications, management, or disease exacerbated by pregnancy Pregnancy Associated Not related to pregnancy Direct OB diseases or management Indirect Preexisting disease aggravated by pregnancy
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Source: JAMWA 2001 MMR Industrialized Nations 1990-1994
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US Historical Perspective: Racial Disparities Sources: MMWR 2003; JAMWA 57(3), 2002
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Trends in Maternal Mortality Ratio NYC, 1993-2002 Source: NYC DOHMH Office of Vital Statistics
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Trends in Maternal Mortality Ratio by Race/Ethnicity NYC OVS, 1993-2002 Source: NYC DOHMH Office of Vital Statistics
Slide 8-

BMIRH MMR Enhanced Surveillance Methods Case ascertainment Vital Statistics, Medical Examiner, SPARCS Case Review Medical records, ME reports, maternal death certificates, infant birth certificates Data entry and analysis
Slide 9-

NYC MMR Review 1998-2000 BMIRH Enhanced Surveillance
Slide 10-

Referral Source of Maternal Deaths BMIRH 1998-2000 * Missing = 3
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CDC/ACOG Categorization of Maternal Deaths BMIRH 1998-2000
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Location of Death BMIRH 1998-2000
Slide 13-

Timing of Death After Delivery BMIRH 1998-2000
Slide 14-

Percent of Live Births and Maternal Deaths By Race/Ethnicity BMIRH 1998-2000 Live Births Maternal Deaths
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Concurrent Morbidity: Obesity BMIRH 1998-2000 (n =169) Obese 24% Not Obese 44% Missing 33% Weight > 200 lbs 20% at delivery
Slide 16-

Comparing Leading Causes of Death (%) *International WHO 1993, JAMWA 2002 **National MMWR 2003 ***NYC BMIRH 1998-2000
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Hemorrhage Related Deaths BMIRH 1998-2000 Black 64 % Hispanic 21 % White 8 % Asian/Pacific Isl. 8 % In hospital 97%
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Hemorrhage Deaths* % Related Cause n=39 Abnormal Coagulation DIC/ Coagulopathy Amniotic Fluid Embolism HELLP syndrome Abruptio placenta Active bleeding Uterine atony Placenta other Placenta previa Unspecified/Unknown * Coagulopathy is the final common pathway 31% 13% 10% 5% 3% 28% 15% 8% 5% 36%
Slide 19-

Pregnancy Outcome % All Deaths vs. Hemorrhage *US data combines abortion and miscarriage
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Obesity: Maternal Mortality Risk From Hemorrhage BMIRH 1998-2000
Slide 21-

Hemorrhage 1/ 1000 deliveries Likely Previa, Abruptio, uterine distension, previous history, Uterine rupture Unanticipated Uterine atony Post partum
Slide 22-

Physiologic Response to Pregnancy Increased vascular volume Decreased systemic vascular resistance Increased HR Increased cardiac output Placental blood flow 500-650 cc/minute Auto transfusion at delivery
Slide 23-

Physiology of Hemorrhage Decreased MAP, CO, CVP, PCWP, SV, Stroke work, O2 consumption, MVO2 Increased SVR, A-V O2 difference, Catecholamine release, HR, PVR, Myocardial contractility Platelet aggregation Small vessel occlusion Impaired microcirculation Embolization to lungs
Slide 24-

Physiology of Hemorrhage Adrenergic effect constriction of venules and small veins Increased venous return (preload) Systemic hypotension Decr capillary hydrostatic pressure Fluid mobilizaton decr blood viscosity
Slide 25-

Physiology of Hemorrhage Anaerobic metabolism Metabolic acidosis Hyperventilation Incr. intra-thoracic pressure Incr. venous return Vasoconstriction Blood redistribution
Slide 26-

Impact of Hemorrhage Hypotenson Oliguria Acidosis Collapse salvage brain, heart, adrenals Fetal cerebral blood flow decr. Acute renal failure Shock liver, lung ARDS Pituitary necrosis
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Mortality Risk Hb < 3.5-5 mg/dl (Hct.10.5-15) Multi organ failure
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ppt slide no 28 content not found
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Replacement fluids Restore Volume with crystalloid NS preferred 3:1 ratio to blood loss Transfuse RBCs Signs of O2 deficiency Consider colloid Albumen Hetastarch
Slide 30-

Transfusion NS only D5W – hemolysis RL - neutralizes citrate anticoagulant Blood used within 4 hours Return to blood bank < 30 minutes Blood warming Administered > 100cc/min Cold => arrhythmia, coagulopathy
Slide 31-

Transfusion Risks Febrile Rxn (> 38C) Allergic Rxn Acute lung injury Septic Rxn (temp increased >2 Deg) Blood born infection HIV - 0.9/1million HTLV - 1/641k Hep C – 1/103K Hep B – 1/250K Calcium depletion Coagulopathy Dilution of clotting factors
Slide 32-

Blood Components
Slide 33-

Other Approaches to Hemorrhage Preop donation Acute normovolemic hemodilution Hemobate (F2 alpha) Rectal Misoprostol Placental bed suture Uterine artery ligation Hypogastric artery ligation Hysterectomy
Slide 34-

Approaches to Hemorrhage Hemorrhage drills Ob, Anesthesiolgy, Blood Bank, Nursing, other staff Experienced operator for anticipated blood loss O neg blood available Organized response team for unanticipated blood loss
Slide 35-

What doesn’t work Preop uterine artery stents Lack of immediate response Crystalloid when blood is needed Delayed operative response Delayed transfusion response