BackgroundMaternal and Perinatal Death Surveillance and Review (MPDSR) can reduce mortality but its implementation is often suboptimal, especially in low- and middle-income countries (LMICs)... Show moreBackgroundMaternal and Perinatal Death Surveillance and Review (MPDSR) can reduce mortality but its implementation is often suboptimal, especially in low- and middle-income countries (LMICs).ObjectivesTo understand the determinants of behaviors influencing implementation of MPDSR in LMICs (through a systematic review of qualitative studies), in order to plan an intervention to improve its implementation.Search StrategyTerms for maternal or perinatal death reviews and qualitative studies.Selection CriteriaQualitative studies regarding implementation of MPDSR in LMICs.Data Collection and AnalysisWe coded the included studies using the Theoretical Domains Framework and COM-B model of behavior change (Capability, Opportunity, Motivation). We developed guiding principles for interventions to improve implementation of MPDSR.Main ResultsFifty-nine studies met our inclusion criteria. Capabilities required to conduct MPDSR (knowledge and technical/leadership skills) increase cumulatively from community to health facility and leadership levels. Physical and social opportunities depend on adequate data, human and financial resources, and a blame-free environment. All stakeholders were motivated to avoid negative consequences (blame, litigation, disciplinary action).ConclusionsImplementation of MPDSR could be improved by (1) introducing structural changes to reduce negative consequences, (2) strengthening data collection tools and information systems, (3) mobilizing adequate resources, and (4) building capabilities of all stakeholders.Implementation of MPDSR could be improved by introducing changes to reduce negative consequences, strengthening data collection tools, mobilizing resources, and building capabilities of all stakeholders. Show less
Vries, P.L.M. de; Deneux-Tharaux, C.; Baud, D.; Chen, K.K.; Donati, S.; Goffinet, F.; ... ; Akker, T. van den 2023
Objective: To compare guidelines from eight high-income countries on prevention and management of postpartum haemorrhage (PPH), with a particular focus on severe PPH.Design: Comparative study... Show moreObjective: To compare guidelines from eight high-income countries on prevention and management of postpartum haemorrhage (PPH), with a particular focus on severe PPH.Design: Comparative study.Setting: High-resource countries.Population: Women with PPH.Methods: Systematic comparison of guidance on PPH from eight high-income countries.Main outcome measures: Definition of PPH, prophylactic management, measurement of blood loss, initial PPH-management, second-line uterotonics, non-pharmacological management, resuscitation/transfusion management, organisation of care, quality/methodological rigour.Conclusions: Our study highlights areas where strong evidence is lacking. There is need for a universal definition of (severe) PPH. Consensus is required on how and when to quantify blood loss to identify PPH promptly. Future research may focus on timing and sequence of second-line uterotonics and non-pharmacological interventions and how these impact maternal outcome. Until more data are available, different transfusion strategies will be applied. The use of clear transfusion-protocols are nonetheless recommended to reduce delays in initiation. There is a need for a collaborative effort to develop standardised, evidence-based PPH guidelines.Results: Definitions of (severe) PPH varied as to the applied cut-off of blood loss and incorporation of clinical parameters. Dose and mode of administration of prophylactic uterotonics and methods of blood loss measurement were heterogeneous. Recommendations on second-line uterotonics differed as to type and dose. Obstetric management diverged particularly regarding procedures for uterine atony. Recommendations on transfusion approaches varied with different thresholds for blood transfusion and supplementation of haemostatic agents. Quality of guidelines varied considerably. Show less
Objective: Analysis of atypical cases of uterine rupture, namely, uterine rupture occurring in unscarred, preterm or prelabour uteri.Design: Descriptive multi-country population-based study.Setting... Show moreObjective: Analysis of atypical cases of uterine rupture, namely, uterine rupture occurring in unscarred, preterm or prelabour uteri.Design: Descriptive multi-country population-based study.Setting: Ten high-income countries within the International Network of Obstetric Survey Systems.Population: Women with unscarred, preterm or prelabour ruptured uteri.Methods: We merged prospectively collected individual patient data in ten population-based studies of women with complete uterine rupture. In this analysis, we focused on women with uterine rupture of unscarred, preterm or prelabour ruptured uteri.Main Outcome MeasuresIncidence, women's characteristics, presentation and maternal and perinatal outcome.Results: We identified 357 atypical uterine ruptures in 3 064 923 women giving birth. Estimated incidence was 0.2 per 10 000 women (95% CI 0.2-0.3) in the unscarred uteri, 0.5 (95% CI 0.5-0.6) in the preterm uteri, 0.7 (95% CI 0.6-0.8) in the prelabour uteri, and 0.5 (95% CI 0.4-0.5) in the group with no previous caesarean. Atypical uterine rupture resulted in peripartum hysterectomy in 66 women (18.5%, 95% CI 14.3-23.5%), three maternal deaths (0.84%, 95% CI 0.17-2.5%) and perinatal death in 62 infants (19.7%, 95% CI 15.1-25.3%).Conclusions: Uterine rupture in preterm, prelabour or unscarred uteri are extremely uncommon but were associated with severe maternal and perinatal outcome. We found a mix of risk factors in unscarred uteri, most preterm uterine ruptures occurred in caesarean-scarred uteri and most prelabour uterine ruptures in 'otherwise' scarred uteri. This study may increase awareness among clinicians and raise suspicion of the possibility of uterine rupture under these less expected conditions. Show less
Tura, A.K.; Girma, S.; Dessie, Y.; Bekele, D.; Stekelenburg, J.; Akker, T. van den; ... ; Ethiopian Obstetric Surveillance 2023
Background: Although the majority of maternal deaths and com-plications occur in low-resource settings, almost all existing strong registration and confidential enquiry systems are found in high ... Show moreBackground: Although the majority of maternal deaths and com-plications occur in low-resource settings, almost all existing strong registration and confidential enquiry systems are found in high -resource settings. We developed and piloted the Ethiopian Obstetric Surveillance System (EthOSS), based on the successful United Kingdom Obstetric Surveillance System (UKOSS) method-ology, in 3 regions in Ethiopia to improve ongoing surveillance and tracking of maternal morbidities and deaths, as well as con-fidential enquiry, compared to the currently used maternal death surveillance and response program in Ethiopia. Methods: We launched the EthOSS monthly case notification sys-tem in 13 hospitals in eastern Ethiopia in April 2021. Study participants included women admitted to the hospitals from April to September 2021 with major adverse obstetric condi-tions during pregnancy, childbirth, or within 42 days of termina-tion of pregnancy. Designated clinicians at the hospitals used a simple online system to report the number of cases and maternal deaths monthly to the EthOSS team. We present findings on the incidence and case fatality rates for adverse conditions included in the EthOSS. Results: Over the 6-month pilot period, 904 women with at least 1 EthOSS condition were included in the study, of whom 10 died (case fatality rate, 1.1%). Almost half (46.6%, 421/904) sus-tained major obstetric hemorrhage, 38.7% (350/904) severe anemia, 29.5% (267/904) eclampsia, 8.8% (80/904) sepsis, and 2.2% (20/904) uterine rupture. To enable care improvement alongside surveillance, the local committee received training on confidential enquiry into maternal deaths from internal and exter-nal experts. Conclusions: In this facility-based project, data on severe ad-verse obstetric conditions were captured through voluntary reporting by clinicians. Further analysis is essential to assess the robustness of these data, and confidential enquiry into maternal deaths for specific cases is planned to investigate the appropri-ateness of care. Show less
Molenaar, J.M.; Meer, L. van der; Bertens, L.C.M.; Vries, E.F. de; Waelput, A.J.M.; Knight, M.; ... ; Struijs, J.N. 2022
Background: Early detection of vulnerability during or before pregnancy can contribute to optimizing the first 1000 days, a crucial period for children's development and health. We aimed to... Show moreBackground: Early detection of vulnerability during or before pregnancy can contribute to optimizing the first 1000 days, a crucial period for children's development and health. We aimed to identify classes of vulnerability among pregnant women in the Netherlands using pre-pregnancy data on a wide range of social risk and protective factors, and validate these classes against the risk of adverse outcomes. Methods: We conducted a latent class analysis based on 42 variables derived from nationwide observational data sources and self-reported data. Variables included individual, socioeconomic, lifestyle, psychosocial and household characteristics, self-reported health, healthcare utilization, life-events and living conditions. We compared classes in relation to adverse outcomes using logistic regression analyses. Results: In the study population of 4172 women, we identified five latent classes. The largest 'healthy and socioeconomically stable'-class [n = 2040 (48.9%)] mostly shared protective factors, such as paid work and positively perceived health. The classes 'high care utilization' [n = 485 (11.6%)], 'socioeconomic vulnerability' [n = 395 (9.5%)] and 'psychosocial vulnerability' [n = 1005 (24.0%)] were characterized by risk factors limited to one specific domain and protective factors in others. Women classified into the 'multidimensional vulnerability'-class [n = 250 (6.0%)] shared multiple risk factors in different domains (psychosocial, medical and socioeconomic risk factors). Multidimensional vulnerability was associated with adverse outcomes, such as premature birth and caesarean section. Conclusions: Co-existence of multiple risk factors in various domains is associated with adverse outcomes for mother and child. Early detection of vulnerability and strategies to improve parental health and well-being might benefit from focussing on different domains and combining medical and social care and support. Show less
Molenaar, J.M.; Meer, L. van der; Bertens, L.C.M.; Vries, E.F. de; Waelput, A.J.M.; Knight, M.; ... ; Struijs, J.N. 2022
BackgroundEarly detection of vulnerability during or before pregnancy can contribute to optimizing the first 1000 days, a crucial period for children’s development and health. We aimed to identify... Show moreBackgroundEarly detection of vulnerability during or before pregnancy can contribute to optimizing the first 1000 days, a crucial period for children’s development and health. We aimed to identify classes of vulnerability among pregnant women in the Netherlands using pre-pregnancy data on a wide range of social risk and protective factors, and validate these classes against the risk of adverse outcomes.MethodsWe conducted a latent class analysis based on 42 variables derived from nationwide observational data sources and self-reported data. Variables included individual, socioeconomic, lifestyle, psychosocial and household characteristics, self-reported health, healthcare utilization, life-events and living conditions. We compared classes in relation to adverse outcomes using logistic regression analyses.ResultsIn the study population of 4172 women, we identified five latent classes. The largest ‘healthy and socioeconomically stable’-class [n = 2040 (48.9%)] mostly shared protective factors, such as paid work and positively perceived health. The classes ‘high care utilization’ [n = 485 (11.6%)], ‘socioeconomic vulnerability’ [n = 395 (9.5%)] and ‘psychosocial vulnerability’ [n = 1005 (24.0%)] were characterized by risk factors limited to one specific domain and protective factors in others. Women classified into the ‘multidimensional vulnerability’-class [n = 250 (6.0%)] shared multiple risk factors in different domains (psychosocial, medical and socioeconomic risk factors). Multidimensional vulnerability was associated with adverse outcomes, such as premature birth and caesarean section.ConclusionsCo-existence of multiple risk factors in various domains is associated with adverse outcomes for mother and child. Early detection of vulnerability and strategies to improve parental health and well-being might benefit from focussing on different domains and combining medical and social care and support. Show less
Engjom, H.; Akker, T. van den; Aabakke, A.; Ayras, O.; Bloemenkamp, K.; Donati, S.; ... ; Knight, M. 2022
Present-day people from England and Wales have more ancestry derived from early European farmers (EEF) than did people of the Early Bronze Age(1). To understand this, here we generated genome-wide... Show morePresent-day people from England and Wales have more ancestry derived from early European farmers (EEF) than did people of the Early Bronze Age(1). To understand this, here we generated genome-wide data from 793 individuals, increasing data from the Middle to the Late Bronze Age and Iron Age in Britain by 12-fold, and western and central Europe by 3.5-fold. Between 1000 and 875 bc, EEF ancestry increased in southern Britain (England and Wales) but not northern Britain (Scotland) due to incorporation of migrants who arrived at this time and over previous centuries, and who were genetically most similar to ancient individuals from France. These migrants contributed about half the ancestry of people of England and Wales from the Iron Age, thereby creating a plausible vector for the spread of early Celtic languages into Britain. These patterns are part of a broader trend of EEF ancestry becoming more similar across central and western Europe in the Middle to the Late Bronze Age, coincident with archaeological evidence of intensified cultural exchange(2-6). There was comparatively less gene flow from continental Europe during the Iron Age, and the independent genetic trajectory in Britain is also reflected in the rise of the allele conferring lactase persistence to approximately 50% by this time compared to approximately 7% in central Europe where it rose rapidly in frequency only a millennium later. This suggests that dairy products were used in qualitatively different ways in Britain and in central Europe over this period. Show less
Patterson, N.; Isakov, M.; Booth, T.; Büster, L.; Fischer, C.; Olalde, I.; ... ; Reich, D. 2021
Present-day people from England and Wales harbour more ancestry derived from Early European Farmers (EEF) than people of the Early Bronze Age1. To understand this, we generated genome-wide data... Show morePresent-day people from England and Wales harbour more ancestry derived from Early European Farmers (EEF) than people of the Early Bronze Age1. To understand this, we generated genome-wide data from 793 individuals, increasing data from the Middle to Late Bronze and Iron Age in Britain by 12-fold, and Western and Central Europe by 3.5-fold. Between 1000 and 875 BC, EEF ancestry increased in southern Britain (England and Wales) but not northern Britain (Scotland) due to incorporation of migrants who arrived at this time and over previous centuries, and who were genetically most similar to ancient individuals from France. These migrants contributed about half the ancestry of Iron Age people of England and Wales, thereby creating a plausible vector for the spread of early Celtic languages into Britain. These patterns are part of a broader trend of EEF ancestry becoming more similar across central and western Europe in the Middle to Late Bronze Age, coincident with archaeological evidence of intensified cultural exchange2-6. There was comparatively less gene flow from continental Europe during the Iron Age, and Britain's independent genetic trajectory is also reflected in the rise of the allele conferring lactase persistence to ~50% by this time compared to ~7% in central Europe where it rose rapidly in frequency only a millennium later. This suggests that dairy products were used in qualitatively different ways in Britain and in central Europe over this period. Show less
Introduction Peripartum hysterectomy is applied as a surgical intervention of last resort for major obstetric hemorrhage. It is performed in an emergency setting except for women with a strong... Show moreIntroduction Peripartum hysterectomy is applied as a surgical intervention of last resort for major obstetric hemorrhage. It is performed in an emergency setting except for women with a strong suspicion of placenta accreta spectrum (PAS), where it may be anticipated before cesarean section. The aim of this study was to compare management strategies in the case of obstetric hemorrhage leading to hysterectomy, between nine European countries participating in the International Network of Obstetric Survey Systems (INOSS), and to describe pooled maternal and neonatal outcomes following peripartum hysterectomy.Material and methods We merged data from nine nationwide or multi-regional obstetric surveillance studies performed in Belgium, Denmark, Finland, France, Italy, the Netherlands, Slovakia, Sweden and the UK collected between 2004 and 2016. Hysterectomies performed from 22 gestational weeks up to 48 h postpartum due to obstetric hemorrhage were included. Stratifying women with and without PAS, procedures performed in the management of obstetric hemorrhage prior to hysterectomy between countries were counted and compared. Prevalence of maternal mortality, complications after hysterectomy and neonatal adverse events (stillbirth or neonatal mortality) were calculated.Results A total of 1302 women with peripartum hysterectomy were included. In women without PAS who had major obstetric hemorrhage leading to hysterectomy, uterotonics administration was lowest in Slovakia (48/73, 66%) and highest in Denmark (25/27, 93%), intrauterine balloon use was lowest in Slovakia (1/72, 1%) and highest in Denmark (11/27, 41%), and interventional radiology varied between 0/27 in Denmark and Slovakia to 11/59 (79%) in Belgium. In women with PAS, uterotonics administration was lowest in Finland (5/16, 31%) and highest in the UK (84/103, 82%), intrauterine balloon use varied between 0/14 in Belgium and Slovakia to 29/103 (28%) in the UK. Interventional radiology was lowest in Denmark (0/16) and highest in Finland (9/15, 60%). Maternal mortality occurred in 14/1226 (1%), the most common complications were hematologic (95/1202, 8%) and respiratory (81/1101, 7%). Adverse neonatal events were observed in 79/1259 (6%) births.Conclusions Management of obstetric hemorrhage in women who eventually underwent peripartum hysterectomy varied greatly between these nine European countries. This potentially life-saving procedure is associated with substantial adverse maternal and neonatal outcome. Show less
McCall, S.J.; Henriquez, D.; Edwards, H.M.; Akker, T. van den; Bloemenkamp, K.W.M.; Bom, J. van der; ... ; Knight, M. 2021
Background This study aimed to compare incidence, management and outcomes of women transfused their blood volume or more within 24 hours during pregnancy or following childbirth.MethodsCombined... Show moreBackground This study aimed to compare incidence, management and outcomes of women transfused their blood volume or more within 24 hours during pregnancy or following childbirth.MethodsCombined analysis of individual patient data, prospectively collected in six international population-based studies (France, United Kingdom, Italy, Australia, the Netherlands and Denmark). Massive transfusion in major obstetric haemorrhage was defined as transfusion of eight or more units of red blood cells within 24 hours in a pregnant or postpartum woman. Causes, management and outcomes of women with massive transfusion were compared across countries using descriptive statistics.FindingsThe incidence of massive transfusion was approximately 21 women per 100,000 maternities for the United Kingdom, Australia and Italy; by contrast Denmark, the Netherlands and France had incidences of 82, 66 and 69 per 100,000 maternities, respectively. There was large variation in obstetric and haematological management across countries. Fibrinogen products were used in 86% of women in Australia, while the Netherlands and Italy reported lower use at 35-37% of women. Tranexamic acid was used in 75% of women in the Netherlands, but in less than half of women in the UK, Australia and Italy. In all countries, women received large quantities of colloid/crystalloid fluids during resuscitation (>3.5 litres). There was large variation in the use of compression sutures, embolisation and hysterectomy across countries. There was no difference in maternal mortality; however, variable proportions of women had cardiac arrests, renal failure and thrombotic events from 0-16%.InterpretationThere was considerable variation in the incidence of massive transfusion associated with major obstetric haemorrhage across six high-income countries. There were also large disparities in both transfusion and obstetric management between these countries. There is a requirement for detailed evaluation of evidence underlying current guidance. Furthermore, cross-country comparison may empower countries to reference their clinical care against that of other countries. Show less
Introduction Peripartum hysterectomy is a surgical procedure performed for severe obstetric complications such as major obstetric hemorrhage. The prevalence of peripartum hysterectomy in high... Show moreIntroduction Peripartum hysterectomy is a surgical procedure performed for severe obstetric complications such as major obstetric hemorrhage. The prevalence of peripartum hysterectomy in high-resource settings is relatively low. Hence, international comparisons and studying indications and associations with mode of birth rely on the use of national obstetric survey data. Objectives were to calculate the prevalence and indications of peripartum hysterectomy and its association with national cesarean section rates and mode of birth in nine European countries.Material and methods We performed a descriptive, multinational, population-based study among women who underwent peripartum hysterectomy. Data were collected from national or multiregional databases from nine countries participating in the International Network of Obstetric Survey Systems. We included hysterectomies performed from 22 gestational weeks up to 48 hours postpartum for obstetric hemorrhage, as this was the most restrictive, overlapping case definition between all countries. Main outcomes were prevalence and indications of peripartum hysterectomy. Additionally, we compared prevalence of peripartum hysterectomy between women giving birth vaginally and by cesarean section, and between women giving birth with and without previous cesarean section. Finally, we calculated correlation between prevalence of peripartum hysterectomy and national cesarean section rates, as well as national rates of women giving birth after a previous cesarean section.Results A total of 1302 peripartum hysterectomies were performed in 2 498 013 births, leading to a prevalence of 5.2 per 10 000 births ranging from 2.6 in Denmark to 10.7 in Italy. Main indications were uterine atony (35.3%) and abnormally invasive placenta (34.8%). Relative risk of hysterectomy after cesarean section compared with vaginal birth was 9.1 (95% CI 8.0-10.4). Relative risk for hysterectomy for birth after previous cesarean section compared with birth without previous cesarean section was 10.6 (95% CI 9.4-12.1). A strong correlation was observed between national cesarean section rate and prevalence of peripartum hysterectomy (rho = 0.67, P < .05).Conclusions Prevalence of peripartum hysterectomy may vary considerably between high-income countries. Uterine atony and abnormally invasive placenta are the commonest indications for hysterectomy. Birth by cesarean section and birth after previous cesarean section are associated with nine-fold increased risk of peripartum hysterectomy. Show less
Heemelaar, S.; Petrus, A.; Knight, M.; Akker, T. van den 2020
Objectives To assess the frequency of maternal death (MD) due to cardiac disease in low- and middle-income countries (LMIC).Methods Systematic review searching Medline, EMBASE, Web of Science,... Show moreObjectives To assess the frequency of maternal death (MD) due to cardiac disease in low- and middle-income countries (LMIC).Methods Systematic review searching Medline, EMBASE, Web of Science, Cochrane Library, Emcare, LILACS, African Index Medicus, IMEMR, IndMED, WPRIM, IMSEAR up to 01/Nov/2017. Maternal mortality reports from LMIC reviewing all MD in a given geographical area were included. Hospital-based reports or those solely based on verbal autopsies were excluded. Numbers of MD and cardiac-related deaths were extracted. We calculated cardiac disease MMR (cMMR, cardiac-related MD/100 000 live births) and proportion of cardiac-related MDs among all MDs. Frequency of cardiac MD was compared with the MMR of the country.Results Forty-seven reports were included, which reported on 38,486 maternal deaths in LMIC. Reported cMMR ranged from 0/100 000 live births (Moldova, Ghana) to 31.9/100 000 (Zimbabwe). The proportion of cardiac-related MD ranged from 0% (Moldova, Ghana) to 24.8% (Sri Lanka). In countries with a higher MMR, cMMR was also higher. However, the proportion of cardiac-related MD was higher in countries with a lower MMR.Conclusions The burden of cardiac-related mortality is difficult to assess due limited availability of mortality reports. The proportion of cardiac deaths among all MD appeared to be higher in countries with a lower MMR. This is in line with what has been called 'obstetric transition': pre-existing medical diseases including cardiac disease are becoming relatively more important where the MMR falls. Show less
Fitzpatrick, K.E.; Akker, T. van den; Bloemenkamp, K.W.M.; Deneux-Tharaux, C.; Kristufkova, A.; Li, Z.Y.; ... ; Knight, M. 2019
Background Amniotic fluid embolism (AFE) remains one of the principal reported causes of direct maternal mortality in high-income countries. However, obtaining robust information about the... Show moreBackground Amniotic fluid embolism (AFE) remains one of the principal reported causes of direct maternal mortality in high-income countries. However, obtaining robust information about the condition is challenging because of its rarity and its difficulty to diagnose. This study aimed to pool data from multiple countries in order to describe risk factors, management, and outcomes of AFE and to explore the impact on the findings of considering United Kingdom, international, and United States AFE case definitions. Methods and findings A population-based cohort and nested case-control study was conducted using the International Network of Obstetric Survey Systems (INOSS). Secondary data on women with AFE (n = 99-218, depending on case definition) collected prospectively in population-based studies conducted in Australia, France, the Netherlands, Slovakia, and the UK were pooled along with secondary data on a sample of control women (n = 4,938) collected in Australia and the UK. Risk factors for AFE were investigated by comparing the women with AFE in Australia and the UK with the control women identified in these countries using logistic regression. Factors associated with poor maternal outcomes (fatality and composite of fatality or permanent neurological injury) amongst women with AFE from each of the countries were investigated using logistic regression or Wilcoxon rank-sum test. The estimated incidence of AFE ranged from 0.8-1.8 per 100,000 maternities, and the proportion of women with AFE who died or had permanent neurological injury ranged from 30%-41%, depending on the case definition. However, applying different case definitions did not materially alter findings regarding risk factors for AFE and factors associated with poor maternal outcomes amongst women with AFE. Using the most liberal case definition (UK) and adjusting for the severity of presentation when appropriate, women who died were more likely than those who survived to present with cardiac arrest (89% versus 40%, adjusted odds ratio [aOR] 10.58, 95% confidence interval [CI] 3.93-28.48, p < 0.001) and less likely to have a source of concentrated fibrinogen (40% versus 56%, aOR 0.44, 95% CI 0.21-0.92, p = 0.029) or platelets given (24% versus 49%, aOR 0.23, 95% CI 0.10-0.52, p < 0.001). They also had a lower dose of tranexamic acid (median dose 0.7 g versus 2 g, p = 0.035) and were less likely to have had an obstetrician and/or anaesthetist present at the time of the AFE (61% versus 75%, aOR 0.38, 95% CI 0.16-0.90, p = 0.027). Limitations of the study include limited statistical power to examine factors associated with poor maternal outcome and the potential for residual confounding or confounding by indication. Conclusions The findings of our study suggest that when an AFE is suspected, initial supportive obstetric care is important, but having an obstetrician and/or anaesthetist present at the time of the AFE event and use of interventions to correct coagulopathy, including the administration of an adequate dose of tranexamic acid, may be important to improve maternal outcome. Future research should focus on early detection of the coagulation deficiencies seen in AFE alongside the role of tranexamic acid and other coagulopathy management strategies.Author summaryWhy was this study done? Amniotic fluid embolism (AFE) is a rare pregnancy complication in which amniotic fluid or foetal material enters the woman's blood stream and triggers a severe reaction. Women with AFE may collapse suddenly during or shortly after they give birth, and it often results in the death of the mother. The rarity of AFE, together with the fact that it is a hard condition to diagnose and several case definitions have been proposed, makes it difficult to obtain reliable information about the condition. What did the researchers do and find? Data on women with AFE ( = 99-218 depending on case definition) collected in five high-income countries were studied along with data on a sample of control women without AFE ( = 4,938) collected in two of the countries. Depending on the definition of AFE used, AFE was found to affect between 1 in every 125,000 to 1 in every 55,000 women giving birth, and between 30%-41% of women with the condition died or had permanent neurological injury. Applying different case definitions resulted in similar findings regarding factors associated with the occurrence of AFE and factors associated with poor maternal outcomes amongst women with AFE. Amongst women with AFE, those with poor maternal outcome were less likely to have had interventions such as platelets to correct blood clotting problems, had a lower dose of tranexamic acid, and were less likely to have had an obstetrician and/or anaesthetist present at the time of the AFE event. What do these findings mean? Our findings suggest that having an obstetrician and/or anaesthetist present at the time of the event and the use of interventions to correct blood clotting abnormalities, including the administration of an adequate dose of tranexamic acid, may be important to improve maternal outcomes in women with AFE. Show less
Lommerse, K.; Knight, M.; Nair, M.; Deneux-Tharaux, C.; Akker, T. van den 2019
Severe obstetric complications are not extensively studied and individual cases are used too little and inappropriately in quality improvement activities, due to limited numbers and prioritization... Show moreSevere obstetric complications are not extensively studied and individual cases are used too little and inappropriately in quality improvement activities, due to limited numbers and prioritization of quantitative research. Nordic and European experts performed a qualitative pilot study using anonymized cases of peripartum hysterectomy. It was feasible to anonymize narratives and we learned lessons in the form of themes for improved clinical care and future research. Therefore, we plan a Nordic anonymized review of the care of women who have undergone peripartum hysterectomy based on narratives. The qualitative outcomes of clinically relevant themes for quality improvement and research will add value to the quantitative analyses from the Nordic medical birth registries. In the longer term, we believe that qualitative audits should be an essential part of the process of continuing improvement in maternity care. Show less
Akker, T. van den; Nair, M.; Goedhart, M.; Schutte, J.; Schaap, T.; Knight, M.; ... ; UK Confidential Enquiry Maternal D 2017
