Maternal MortalityMaternal Mortalityand Hemorrhageand Hemorrhage

Gina M. Brown, MDNYC Department of Health and Mental Hygiene

Bureau of Maternal, Infant and Reproductive Health

Special Thanks to:Candace Mulready, MPHKatrina Manzano, MPHVani Bettegowda, MHSOffice of Vital StatisticsOffice of the City Medical ExaminerSPARCS

Bureau of Maternal, Infant and Reproductive Health

Maternal Mortality RatioDeaths/100,000 live births during pregnancy or within 1year of termination. A ratio not a rate: cannot count total #pregnancies

PregnancyRelated OBcomplications,management, ordisease exacerbatedby pregnancy

PregnancyAssociatedNot related to pregnancy

DirectOB diseases ormanagement

IndirectPreexisting diseaseaggravated by pregnancy

Source: JAMWA 2001

MMR Industrialized Nations1990-1994

US Historical Perspective:US Historical Perspective:Racial DisparitiesRacial Disparities

4.1126.76.51990

3.7030.08.11991-1999

3.64222.061.01950

2.59445.0172.01945

1.951174.0601.01930

1.761056.0601.01915

Risk RatioMMR BlackMMR WhiteYear

Sources: MMWR 2003; JAMWA 57(3), 2002

Trends in Maternal Mortality RatioTrends in Maternal Mortality RatioNYC, 1993-2002

Per

100,

000

Live

Birt

hs

Source: NYC DOHMH Office of VitalStatistics

Trends in Maternal Mortality Ratio byRace/EthnicityNYC OVS, 1993-2002

Per

100,

000

Live

Bir

ths

Source: NYC DOHMH Office of VitalStatistics

BMIRH MMR EnhancedBMIRH MMR EnhancedSurveillance MethodsSurveillance Methods

Case ascertainment– Vital Statistics, Medical Examiner,

SPARCSCase Review– Medical records, ME reports, maternal

death certificates, infant birthcertificates

Data entry and analysis

NYC MMR Review 1998-2000NYC MMR Review 1998-2000BMIRH Enhanced SurveillanceBMIRH Enhanced Surveillance

169 (60%)108Total54 (60%)34200063 (30%)49199952 (110%)251998

# Cases BMIRH(enhanced surveillance

including OVS) # Cases OVSYear

Referral Source of Maternal DeathsReferral Source of Maternal DeathsBMIRH 1998-2000BMIRH 1998-2000

47

8

22

17

Not related

166*3881Total

26810SPARCS

3264OCME

1082467OVS

TotalIndirectDirectSource

* Missing = 3

CDC/ACOG Categorization ofCDC/ACOG Categorization ofMaternal DeathsMaternal Deaths

BMIRH 1998-2000BMIRH 1998-2000

05

101520253035404550

Per

cent

Preg Rel Direct Preg Rel Indirect Preg not related

Location of DeathLocation of DeathBMIRHBMIRH 1998-20001998-2000

0

10

20

30

40

50

60

70

80

Hospital EMR Home In Transit

Perc

ent

Timing of Death After DeliveryTiming of Death After DeliveryBMIRH 1998-2000BMIRH 1998-2000

05

101520253035404550

<24 hrs 24h-1wk > 1wk- 42days >42 days

Perc

ent

Percent of Live Births and MaternalPercent of Live Births and MaternalDeaths By Race/EthnicityDeaths By Race/Ethnicity

BMIRH 1998-2000BMIRH 1998-2000

0

10

20

30

40

50

60

Race/Ethnicity

Perc

ent

0

10

20

30

40

50

60

Race/Ethnicity

WhiteBlackHispanicAsian/Pacific Isl

Live Births Maternal Deaths

Concurrent Morbidity: ObesityConcurrent Morbidity: ObesityBMIRH 1998-2000 BMIRH 1998-2000 (n =169)(n =169)

Obese 24%Not Obese 44%Missing 33%

Weight > 200 lbs 20%at delivery

Comparing LeadingComparing LeadingCauses of Death (%)Causes of Death (%)

Cardiomyopathy8%Anesthesia 7%

Cardiomyopathy8%CVA 5.0%Anesthesia 2%

Obstructed Labor8%Unsafe Ab 13%

Other

7%13%15%Infection/Sepsis

32%17%25%Hemorrhage

10%16%12%Hypertensive Disorders

7%20%NegligibleEmbolism

NYC PRMRN=119

National PRMRN=4200**

InternationalPRMR*

Cause

*International WHO 1993, JAMWA 2002

**National MMWR 2003

***NYC BMIRH 1998-2000

Hemorrhage Related DeathsHemorrhage Related DeathsBMIRH 1998-2000BMIRH 1998-2000

• Black 64 % • Hispanic 21 % • White 8 %• Asian/Pacific Isl. 8 %

• In hospital 97%

Hemorrhage Deaths*Hemorrhage Deaths*% % Related CauseRelated Cause

n=39n=39Abnormal Coagulation– DIC/ Coagulopathy– Amniotic Fluid

Embolism– HELLP syndrome– Abruptio placenta

Active bleeding– Uterine atony– Placenta other– Placenta previa

Unspecified/Unknown

* Coagulopathy is the finalcommon pathway

31%13%10%5%3%

28%15%8%5%

36%

Pregnancy Outcome %Pregnancy Outcome %All Deaths vs. HemorrhageAll Deaths vs. Hemorrhage

335518

1354

NYCHemorrhage

Deaths (n=39)

8232113

844

All NYC Maternal Deaths

(n=169)

47Ectopic

10Unknown

8Undelivered

0.2Molar

8*

InducedAbortion/miscarriage

12Stillbirth

14Live Birth

USHemorrhage

Deaths (n=470)PregnancyOutcome

*US data combines abortionand miscarriage

Obesity: Maternal Mortality RiskObesity: Maternal Mortality RiskFrom HemorrhageFrom Hemorrhage

BMIRH 1998-2000BMIRH 1998-2000

414471No

213312Missing

383.88

[1.82, 8.26]

242.24

[1.5, 3.34]

17Yes

MaternalHemorrhage Deaths

(n=39; % of total)OR [CI]

Maternal Deaths(n=169)% of total,

OR [CI]

NYC Live Births1998-2000

(n=373,554; % oftotal)

Obesity

HemorrhageHemorrhage

• 1/ 1000 deliveries• Likely

• Previa, Abruptio, uterine distension,previous history, Uterine rupture

• Unanticipated• Uterine atony• Post partum

Physiologic Response toPhysiologic Response toPregnancyPregnancy

• Increased vascular volume• Decreased systemic vascular

resistance• Increased HR• Increased cardiac output• Placental blood flow 500-650

cc/minute• Auto transfusion at delivery

Physiology of HemorrhagePhysiology of Hemorrhage

• Decreased• MAP, CO, CVP, PCWP, SV, Stroke work,

O2 consumption, MVO2• Increased

• SVR, A-V O2 difference, Catecholaminerelease, HR, PVR, Myocardialcontractility

• Platelet aggregation• Small vessel occlusion• Impaired microcirculation• Embolization to lungs

Physiology of HemorrhagePhysiology 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

Physiology of HemorrhagePhysiology of Hemorrhage

• Anaerobic metabolism• Metabolic acidosis• Hyperventilation

• Incr. intra-thoracic pressure• Incr. venous return

• Vasoconstriction• Blood redistribution

Impact of HemorrhageImpact of Hemorrhage• Hypotenson• Oliguria• Acidosis• Collapse

• salvage brain, heart,adrenals

• Fetal cerebral bloodflow decr.

• Acute renal failure• Shock liver, lung• ARDS• Pituitary necrosis

Mortality RiskMortality Risk

• Hb < 3.5-5 mg/dl (Hct.10.5-15)• Multi organ failure

RBC,Crystalloid,Colloid

ObtundedOliguria/anuriaCV collapse

> 40%> 2500IV

CrystalloidColloid,RBCs

Incr HR, RRDecr BP,Oliguria

25-40%1501-2500III

Crystalloid,Incr. HR,orthostasis,mentalDecr caprefill

15-25%1001-1500II

CrystalloidOrthostatictachycardia

15%< 1000 ccI

RxSpxVolumeDeficit

BloodLoss

Class

Replacement fluidsReplacement fluids

• Restore Volume with crystalloid• NS preferred• 3:1 ratio to blood loss

• Transfuse RBCs• Signs of O2 deficiency

• Consider colloid• Albumen• Hetastarch

TransfusionTransfusion

• 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

Transfusion RisksTransfusion 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

Blood ComponentsBlood Components

Fibrinogenreplacement

Factor 8c,VW factorFibrinogen

50-75ccCryoprecipitate

PT, PTT> 1.5x nl, INR >1.6

Fibrinogen,clottingfactors

100ccFFP

1u = 5000uLPlateletsWBC Ag

30-50ccPlatelets

1u = 1g/dlHb

Hct. 70-80%200-250 ccPRBC

1u =1g/dl HbHct. 36-44%450-500 ccWhole blood

Indication/Utility

ComponentVolumeProduct

Other Approaches toOther Approaches toHemorrhageHemorrhage

• Preop donation• Acute normovolemic hemodilution• Hemobate (F2 alpha)• Rectal Misoprostol• Placental bed suture• Uterine artery ligation• Hypogastric artery ligation• Hysterectomy

Approaches to HemorrhageApproaches 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

What doesn’t workWhat doesn’t work

• Preop uterine artery stents• Lack of immediate response• Crystalloid when blood is needed• Delayed operative response• Delayed transfusion response