Er fødsel farlig for mor i Norge? Severe maternal morbidity

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1 Er fødsel farlig for mor i Norge? Severe maternal morbidity 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 1

2 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 2

3 -Half a million women die every year from maternal causes world wide -99% are from developing countries. - A pregnant woman has one foot in the grave Traditional African saying. 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 3

4 Maternal Mortality Ratio 400/ Worldwide 21/ in developed world 440/ in developing world 1000/ Sub-Saharan Africa 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 4

5 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 5

6 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 6

7 -Reduction of 98% in maternal mortality in Norway in the last 100 years. -Maternal Mortality Rate( ): 4/ Is it safe to deliver in Norway? 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 7

8 Maternal mortality,uk( ): 13.1/ Direct deaths: 5.3 / Indirect deaths: /02/2008 Iqbal AL-Zirqi, Rikshospitalet 8

9 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 9

10 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 10

11 Maternal mortality in Norway : 47 deaths. 14 Hypertensive (30%) 5 CS 5 Thrombo/embolism 4 Amniotic fluid embolism 4 Infection 4 Ectopic 3 Cerebrovascular 2 uterus rupture 1 bleeding 5 others 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 11

12 -Bleeding was the main cause of deaths in 1970s ; Now: hypertensive diseases are dominating. -CS was not registered as a cause in 1970s -Increased maternal mortality among older women. 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 12

13 2 extremes: 1- Wishes for Home deliveries. 2- CS on request. The forgotten fact: Little knowledge about severe complications around delivery, neither in Norway, nor in other Western countries. 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 13

14 Severe maternal morbidity -Life- threatening conditions in mothers who may die, But survive due to access of high quality emergency obstetric care. -Incidence in the West: 0,05-1,2%; Small retrospective studies; No reproducible definition. 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 14

15 M.O.M.S. Survey B -Mother s Mortality & Severe morbidity Multi-center,multi-country population-based cohort in 9 European countries including Norway cases in deliveries Incidence: 9.5/1000 (6-14.7/1000). 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 15

16 Selected severe morbidity -Severe Pre-eclampsia: PE + one or more of: 1-BP >170/ Proteinuria > 2gm/24h or 3+ on dipstick. 3- Oliguria < 500m/24h. 4 - Epigastric pain. 5- Headache 6- Pulmonary oedema. 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 16

17 -Eclampsia: convulsions during pregnancy or first 10 days postpartum in relation to PE -HELLP syndrome: platelets < 100, increased liver enzymes & hemolysis 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 17

18 -Severe bleeding:blood loss > 1500ml; Blood transfusion >4 units ;Hb drop >4gm/dl -Sepsis:Bacteremia plus 2 or more of:temp. >38.puls >90, resp.rate>20, WBC > 12x10 9 /l or <4x /02/2008 Iqbal AL-Zirqi, Rikshospitalet 18

19 M.O.M.S-B Severe bleeding 4.6/1000 Severe pre-eclampsia 4.3/1000 Sepsis 0.8/ /02/2008 Iqbal AL-Zirqi, Rikshospitalet 19

20 Incidence/1000 deliveries All Severe PE S.bleeding Sepsis Austria Belgium Finland France Hungary Irland Italy Norway UK Total /02/2008 Iqbal AL-Zirqi, Rikshospitalet 20

21 UK Study( ) -Prospective multi-centre study in South East Thames cases in deliveries over 24 weeks- Incidence: 1,2%. -Morbidity/Mortality ratio: 118/1 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 21

22 Severe bleeding Pre-eclampsia 55,6% (1 death) 38% (1 death) Severe sepsis 3% (3 deaths) Uterus rupture 2% Others 1,3% PE(83,5% Severe,5% Eclampsia, HELLP 11%) 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 22

23 Risk Factors -Age over 34 -Non white -Social exclusion -Diabetes & hypertension. -Previous PPH, Multiple pregnancy, 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 23

24 Antenatal admission Emergency CS Anaemia Antiepelptics Antidepressants Induction of labour Manual removal of placenta 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 24

25 Oslo Study( ) Aker RH Total Deliveries Cases Incidence 1% B. Stray-Pedersen 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 25

26 Aker RH Total All PE (39%) Sepsis (32%) Bleeding (29%) 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 26

27 Characteristics Age 28,5 yrs P0 67% Admission before delivery 31% CS 63% 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 27

28 Conclusion -High incidence of severe morbidity. -If representative, then 600 mothers develop lifethreatening complications yearly, may be even more. -Sepsis was associated with CS; 68% Of sepsis cases had CS. 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 28

29 -Maternal mortality is rare; Morbidity is more frequent: rapid & more information to assess obstetric care/risk management. 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 29

30 Our Project (Kk/folkehelse) -Incidence &risk factors of severe maternal morbidity in Norway. -Sources: 1-MFR 2-Medical Journals;Casecontrol study 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 30

31 Incidence of severe complications among mothers in Norway Severe PE 1.1% Eclampsia 0.1% HELLP 0.2% Severe bleeding 1.1% Sepsis 0.1% Uterus rupture 0.03% Pulmonary embolus 0.01% Others 0.02% All 2.65% 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 31

32 Causes of severe bleeding in 3501 cases Uterine atony 30.10% Retained placenta 18.93% Deep vaginal & perineal 12.00% injuries Placental abruption 3.00% Placenta previa 2.50% Cervical injuries 1.30% Uterine rupture 0.42% Coagulopathy 0.68% Non identified 30.79% 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 32

33 Risk factors of severe bleeding Variable Adjusted OR, (95% CI) Age Age ( )** 1.45 ( )*** Para ( )*** South East Asian Middle Eastern 1.79 ( )*** 0.61 ( )** 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 33

34 Cardiac disease 1.50 ( )* Multiple pregnancy 2.41 ( )*** Hb < 9 gm/dl 2.25 ( )*** Previous section 1.53 ( )*** HELLP syndrome 1.91 ( )** Induction of labour 1.63 ( )*** Prolonged labour 1.45 ( )*** Macrosomia 1.90 ( )*** Elective section Emergency section 2.32 ( )*** 3.12 ( )*** ***= P<0.001 **= P>0.001<0.01 *=P>0.01< /02/2008 Iqbal AL-Zirqi, Rikshospitalet 34

35 The Other Face of a Tragedy 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 35

36 I did my best but it just was not good enough. I am wondering if I am in the right job. I decided as a result to give up my career. I was not suitable for the job and she died as a result. I blame myself constantly. I did not have the necessary knowledge and i am now looking for less stressful work. 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 36

37 Where is the support? Where is risk management? 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 37

38 Main Aim Find the extent &the impact of severe maternal morbidity. Remind us that it is inappropriate to reduce vigilance and resources that assure maternal safety. Establish clinical risk management! 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 38

39 Takk for meg! 19/02/2008 Iqbal AL-Zirqi, Rikshospitalet 39

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