Rozbor mateřské úmrtnosti v ČRv roce 2000

Analysis of Maternal Mortality in theCzech Republic in 2000

Objective:
Analysis of maternal mortality in the Czech Republic in 2000.Design: Retrospective statistical and clinical analysis.Setting: Department of Obstetrics and Gynecology of the 1st Medical School of Charles Universityand General University Hospital, Prague 2, Institute for the Care of Mother and Child, Prague.Introduction: We present an annual analysis of maternal mortality in the Czech Republic, organizedinto two parts: 1) international statistical part, and 2) clinical part in Czech only with abbreviatedanonymous analysis of individual cases of maternal death. We are aware that follow-upanalysis cannot fully express dramatic situations around all cases or reproduce in details all theiraspects. We though believe that this form will help to our gynecologists to learn about courses ofthe deaths, particularly when the frequency of such cases is low and circumstances are unusual.Individual analyses include also conclusions of expert committees or analyses performed by theCzech Medical Chamber. Comments and notes however are not for forensic purposes and are usedonly for medical ones.Methods: We used a database of 10 cases of maternal deaths in the Czech Republic in 2000. Weanalyzed their causes, clinical courses, especially in connection to obstetrical surgery, and ade-quacyof provided care.Results: There were 10 reported maternal deaths in connection to pregnancy, labor and deliveryor within 42 days after delivery in the Czech Republic in 2000. There were 90 910 live-born babiesand total, gross maternal mortality (A+B+C) was 0.11 per 1000, i.e. 11 deaths per 100 000 live-bornbabies. This is only 0.02 per 1000 better than results in 1999 (Table 3 shows data on maternalmortality for last 10 years).In 2000, there was one maternal death unrelated to gestation – category C, therefore maternalmortality in connection to gestation (A+B) was 0,099 per 1000 i.e. 9.9 deaths per 100 000 live-bornbabies compared to 10.1 deaths in 1999. The causes of deaths were different. Only two womenwere within group A (specific risk – direct maternal mortality), therefore direct maternal mortalitywas 2.2 per 100 000 live-born babies. Seven maternal deaths were in the group B (non-specificrisk – indirect maternal mortality) and indirect maternal mortality was unusually high, 7.7 per100 000 live-born babies. It is difficult to judge the difference due to possible error of smallnumbers. The demographic part of the report has been sent to the Office of Health Statistics andInformation and detailed report to the Department of Health Care of the Ministry of Health of theCzech Republic.Conclusions: Since 1994, when we introduced nationwide organization measures to identify riskgroups of pregnant women and use of micro-heparinization among those, we have succeeded tolower the frequency of thrombolism, till then leading cause of maternal deaths, especially in linksto operative deliveries and in smaller extent among high-risk women during pregnancy. Thedecrease of maternal mortality was substantial, by 50%, however only temporary, followed bya partial increase to about 10 maternal deaths per 100 000 live-born babies. This increase was toincreased frequency of coagulopathies, HELLP syndrome, and, in 2000, due to non-specific cardiovascularcauses and some neurologic complications. The majority of these cases and especiallythose with non-adequate obstetrical care will be anonymously analyzed together with responsiblechiefs of ob/gyn departments during perinatology conference in 2002 and results will be consequentlypublished.Increase of non-specific causes of maternal deaths in 2000, especially of those with cardiovascularcomplications, indicate a necessity to be careful especially with older parturients, diabetic women,obese women and „dangerous“ multiparae, where the possibility of cardiovascular complicationsmight require need concentrated medical diagnosis. Primary attention, though, should beaimed at impaired coagulation of blood. The cases of complications of DIC persistently showinsufficient diagnostic and therapeutic measures especially in small facilities with limited laboratorycompartments, outdated and wrong therapeutic measures and almost missing potential forconsultancy. In spite of this it is particularly necessary to concentrate on prevention among caseswith higher risk for DIC. We have concentrated on publications in collaboration with hematologistsand anesthesiologists in this field, although some measures are lacking the universal consent,especially some therapeutic means. It is very important to us that chiefs of ob/gyndepartments are open for professional discussions, although some situations are prone to forensicevaluation. We believe that our approach of anonymous analyses with two-year delay is sufficientfor necessary audit of maternal mortality.

Key words:
thromboembolism, disseminated intravascular coagulopathy, maternal mortality,HELLP sy