Perinatology clinic in the coronavirus disease-2019 pandemic: what harms, often teaches.

BACKGROUND: Compartmental models simplify the mathematical modeling of infectious diseases based on reported cases. In the absence of precautions, personal protective equipment, quarantine and social distancing, a Susceptible-Exposed-Infectious-Recovered (SuEIR) model with Unscented Kalman Filter for coronavirus disease-19 (COVID-19) Forecasts in Turkey has revealed 174 641 infected people on August 15, 2020, whilst the reported case was 12 216. Through numerical experiments, the effects of quarantine, social distancing, and COVID-19 testing on the dynamics of the outbreak varies. We herein present the documentation of the work in a perinatology clinic during COVID-19 pandemic to find the reflection in a pandemic hospital as even in the pandemic, pregnancy complications and fetal diagnosis/therapy are time-sensitive and cannot be delayed. During the prevention of the horizontal transmission to the health-care workers (HCWs), testing all pregnant women with nasopharyngeal/oropharyngeal swabs for severe acute respiratory syndrome coronavirus (SARS-COV-2) undergoing birth, ultrasound examinations, invasive procedures appear to be the gold standard so that appropriate precautions can be taken if the screen is positive. Though it is logical, it may be incompatible with a busy obstetric practise as a pending polymerase chain reaction (PCR) result should never delay any emergent procedure. OBJECTIVE: We aim to describe the development of COVID-19 disease of 408 HCW out of 1462 by the exposure to pregnant women while providing obstetric care in a single tertiary perinatology unit under strict clinical triage, recommended precautions and wearing personal protective equipment and compare the maternal and perinatal outcome with those of the preceding three months. STUDY DESIGN: A prospective cohort study involving the pregnant women and the HCW with positive PCR for SARS-COV-2 were carried out to correlate with the horizontal transmission while documenting the perinatal work. RESULTS: 25 HCW, including nurses/midwives: 11, doctors: 7 and health technicians: 3 and support staff: 4 developed positive PCR for SARS-COV-2 while providing healthcare to 162 cases: mild-moderate (n = 146), severe (n = 12) and critical (n = 1) and asymptomatic (n = 3) in obstetric population. 22 out of 25 HCW were working in the perinatology unit. COVID-19 clinic was asymptomatic (n = 8), mild-moderate (13) or severe (n = 2) in HCW. However, "Exposed" group in the SuEIR model, both the pregnant women and the HCW that have already been infected and have not been tested, which have been also capable of infecting the "Susceptible" group could not be determined. Some of the HCW and the pregnant women in the "Exposed" group were tested and transferred to the "Infectious" group (which were reported to be PCR positive), while the rest of them who recovered, transitted to the so-called "Unreported Recovered" group. The ratio of the women with severe pre-eclampsia admitted to intensive care unit increased significantly during the lockdown (p = .01). CONCLUSIONS: In a nonstop pandemic perinatology clinic, exposure to 162 PCR positive pregnant women may be correlated with a 5.4% (22/408) documented horizontal transmission in the frontline HCW despite clinical triage and personal protective equipment.

The effect of real-time polymerase chain reaction cycle threshold values on perinatal outcomes of pregnant women with COVID-19.

OBJECTIVE: To evaluate the effect of cycle threshold (Ct) values on the pregnancy outcomes of women with coronavirus disease 2019 (COVID-19). MATERIALS AND METHODS: This prospective cohort study was conducted on pregnant women with COVID-19. A real-time polymerase chain reaction (RT-PCR) assay of a nasopharyngeal and oropharyngeal specimen was used for the diagnosis. Initial Ct values for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RT-PCR tests were recorded. 22.9 was the 50th percentile Ct value of the study population. The study population was divided into two groups based on their Ct values: (1) Cases with Higher Ct values (Ct > 22.9)(n = 50) and (2) Cases with lower Ct values (Ct ≤ 22.9)(n = 55). Demographic features, clinical characteristics, disease progression, laboratory test results and pregnancy outcomes were compared between the groups. A receiver operating characteristic (ROC) curve was used to assess the performance of Ct values in predicting obstetric complications. RESULTS: Obstetric complication rate was significantly higher in cases with lower Ct values (p < .001). A significantly lower lymphocyte count together with higher ESR, procalcitonin and IL-6 values were observed in the cases with lower Ct values (p > .05). Additionally, a significantly higher NICU admission rate and longer hospital stays were present in the cases with lower Ct values (p > .05). The value in ROC curves with the best balance of sensitivity/specificity was 22.5 (85.7% sensitivity, 63.6% specificity). CONCLUSION: Lower Ct values may be associated with an increased rate of obstetric complications in pregnant women with COVID-19. Physicians should be cautious in the management of cases with Ct levels below 22.5.

An analysis of the high cesarean section rates in Turkey by Robson classification.

BACKGROUND: Cesarean deliveries outnumbered vaginal deliveries in Turkey. The aim of this study is to analyze the CS rates, sizes of the groups and their contribution to CS in the Robson10-Group Classification to address the main drivers that are associated with an increase in CS rates in Turkey by comparing with the customized benchmark, World Health Organization (WHO) Multi-country Survey Reference (MCS) population. We also evaluate the existence of the Pareto principle that states that for many phenomena, about the 80% of the consequences (increase in CS rate) are produced by 20% of the causes. METHODS: In Turkey, 1503 facilities (public hospitals: 879, private hospitals: 557, university hospitals: 67) provided delivery services for 1 266 300 women in 2017. The distribution of this number to public, private and university hospitals were 630 688 (49.8%), 565 441 (44.7%) and 70 171 (5.5%), respectively. The Ministry of Health in Turkey has established a registration system to analyze the increase in CS rates. by implementation of the Robson's classification. We analyzed the electronic records of 887 683 women sent from public: 554 916/630 688 (87.98%), private: 297 724/565 441 (52.65%) and university 35, 043/70.171 (49.93%) hospitals. RESULTS: Overall CS rate was 51.2%. CS rates in public, private and university hospitals were 39.7, 70.6 and 70.3%, respectively (p < .0001), depicting significant differences for each sector. CS rates were higher than WHO MCS reference population for all Robson groups. Further evaluation was performed to reveal the rank order of Robson groups affecting on the CS rates. Groups 5, 1, 3, 2, 4 and 10 were the six groups constituting more than 80% of the women in healthcare facilities. Analysis of the data revealed the following conclusions in terms of the size of the group and the contribution of each group to total CS rate: Women in Group 5 played the dominant role with a 25.2% in size of the group and 24.4% contribution to the CS rate. Domino effect of the group 5 with both its size and contribution to CS was prominent. 32.3 percent of the women included in Robson Groups 1 and 2. Though CS rate under 10% was reported to be achievable for Robson Group 1 in the WHO MCS reference population, total CS rate was 19.6% in Turkey. In Robson Group 2, CS rate was reported to be 39.9% in the WHO MCS reference population, while the CS rate was 59.6% in Turkey. The size of Robson groups 3 and 4 included 32.9%. Contribution of both groups to CS rate was 5.6%. CS rates for group 3 and 4 were 11.2 and 36.8%, respectively, whereas those were reported to be 3.0% in Group 3 and 23.7% in Group 4 for the WHO MCS reference population. All singleton pregnancies <37 weeks in Robson group 10 constituted 3.1% of the whole group with a 2.3% contribution to the CS rate. Total CS rate for Robson group 10 was 70.5% in Turkey whereas it was reported to be 25.3% for WHO MCS reference population. CONCLUSIONS: Robson classification in Pareto diagrams for each sector identified the main contributors to the CS rate as Groups 5, 3, 2, 1, 4 and 10 not only to target groups that may benefit from implementations or interventions but also guide public policies and investments for reducing CS rates in Turkey. Consequences of the commercialization on the health care system is apparent. Policies should be directed at the private sector, where 44.7% of the deliveries occur and where CS indication seems not to be driven by medical reasons completely.

Placenta percreta-induced uterine rupture with right ovarian vein thrombus protracting into the inferior vena cava.

In Turkey, the triad of prior cesarean section (CS), placenta previa, and placenta accreta spectrum is worth of concern. Here, we present an unpublished complication of placenta percreta-induced uterine rupture: ovarian vein thrombosis (OVT) protracting into the inferior vena cava (IVC) in a woman with a previous CS and placenta previa. We propose the integration of the sub-xiphoid transabdominal long axis of the IVC into the point-of-care ultrasound practice with color Doppler to establish the diagnosis of complicated OVT. To prevent placenta accreta spectrum-related complications, there is an urgent need to lower CS rate both globally and in Turkey.

The rate of SARS-CoV-2 positivity in asymptomatic pregnant women admitted to hospital for delivery: Experience of a pandemic center in Turkey.

OBJECTIVE: To investigate the rate of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positivity in asymptomatic pregnant women admitted to hospital for delivery in a Turkish pandemic center. STUDY DESIGN: This prospective cohort study was conducted in Ankara City Hospital between April, 15, 2020 and June, 5, 2020. A total of 206 asymptomatic pregnant women (103 low-risk pregnant women without any defined risk factor and 103 high-risk pregnant women) were screened for SARS-CoV-2 positivity upon admission to hospital for delivery. Detection of SARS-CoV2 in nasopharyngeal and oropharyngeal samples was performed by Real Time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) method targeting RdRp (RNA dependent RNA polymerase) gene. Two groups were compared in terms of demographic features, clinical characteristics and SARS-CoV-2 positivity. RESULTS: Three of the 206 pregnant women participating in the study had positive RT-PCR tests (1.4 %) and all positive cases were in the high-risk pregnancy group. Although, one case in the high-risk pregnancy group had developed symptoms highly suspicious for COVID-19, two repeated RT-PCR tests were negative. SARS-CoV-2 RT-PCR positivity rate was significantly higher in the high-risk pregnancy group (2.9 % vs 0%, p = 0.04). CONCLUSION: Healthcare professionals should be cautious in the labor and delivery of high-risk pregnant women during the pandemic period and universal testing for COVID-19 may be considered in selected populations.

The Relationships between Prenatal Attachment, Basic Personality Traits, Styles of Coping with Stress, Depression, and Anxiety, and Marital Adjustment Among Women in the Third Trimester of Pregnancy.

OBJECTIVE: The importance of prenatal attachment, probably as the initial attachment of a pregnant woman to the fetus and which turn into the maternal-baby attachment after birth, for the well-being of the newborn and mother is well known. The aim of the present study was to explore the possible socio-demographic and clinical factors (personality features, styles used in coping with stress, depression, and situational anxiety levels, and marital adjustment) affecting maternal-fetal attachment. MATERIALS AND METHODS: Eighty women on their third trimesters of pregnancy were included in the study. After examination by a psychiatrist, a detailed socio-demographic form and scales including Prenatal Attachment Inventory, Basic Personality Traits Scale, Coping with Stress Attitudes Inventory, State-Trait Anxiety Inventory-1, Beck Depression Inventory (BDI), and Marital Adjustment Scale were applied. RESULTS: Educational level, marital adjustment, social support, and turning to religion as a coping mechanism with stress were found to be positively correlated with prenatal attachment scores. The duration of marriage and number of giving births and the avoidance/disengagement subscale of Coping with Stress Scale and BDI scores were negatively correlated with prenatal attachment scores. A BDI score of ≥17 (this score suggests moderate and/or severe symptoms of depression) was found to be an independent and a negative variable on prenatal attachment. CONCLUSION: We suggest that the detection of symptoms of depression and other factors that may affect prenatal attachment, may help shed light to the interventions to be performed to improve the quality of maternal-fetal attachment by society and governments.

Aortic Arch Thrombosis Associated with Fetal Cytomegalovirus Viremia.

Cytomegalovirus(CMV) associated thrombosis has been reported sporadically in the medical literature; however, its antenatal scenario has not been documented. We herein present the antenatal, Doppler's ultrasound and magnetic resonance angiographic features of thrombosis in the aortic arch showing extension toward the medial lumen of the brachiocephalic trunk with critical occlusion of the left common carotid artery and left subclavian artery in a term fetus to raise obstetricians'/ neonatologists'/pediatric cardiologists' awareness for the association between CMV viremia and intrauterine thrombosis that caused cerebral injury, neurodevelopmental impairment, and permanent sequela.

The Influence of Maternal Obesity on Pregnancy Complications and Neonatal Outcomes in Diabetic and Nondiabetic Women.

INTRODUCTION: This study aimed to investigate the influence of obesity on pregnancy complications and neonatal outcomes in diabetic and nondiabetic women. MATERIALS AND METHODS: This retrospective case control study was conducted on 1193 pregnant women and their neonates at a tertiary level maternity hospital between March 2007 and 2011. The pregnant women were classified into 2 groups according to the presence of diabetes mellitus. Six hundred and seven patients with gestational diabetes or pregestational diabetes formed the diabetic group (study group) and 586 patients were in the nondiabetic group (control group). Demographic characteristics, body mass index, gestational weight gain, obstetric history, smoking status, type of delivery, gestational ages, pregnancy complications, neonatal outcomes were recorded for each patient. Multivariable logistic regression analysis was performed to evaluate the effect of obesity and diabetes on the pregnancy complications and neonatal outcomes. RESULTS: The mean age and pre-pregnancy body mass indices of women with diabetes mellitus were significantly higher than the control group's (p < 0.001). Gestational weight gain and number of smokers were similar among the groups. Multiparity and obesity were more prevalent in the diabetic group compared to controls (both p < 0.001). Although gestational age at birth was earlier in the diabetic group, birth weights were higher in this group than in the control group (both p < 0.001). Cesarean delivery rates, the incidence of macrosomia, and neonatal intensive care unit admission rates were significantly higher in the diabetes group both with normal and increased body mass index (all p < 0.001). However, adverse pregnancy outcomes were comparable between the groups (p = 0.279). Multivariable logistic regression analysis showed that obesity is a significant risk factor for pregnancy complications (OR = 1.772 [95% CI, 1.283 - 2.449], p = 0.001) but not for adverse neonatal outcomes (OR = 1.068 [95% CI, 0.683 - 1.669], p = 0.773). CONCLUSION: While obesity increases risk of developing a pregnancy complication, diabetes worsens neonatal outcomes.

Factors contributing to adverse maternal outcomes in patients with HELLP syndrome.

OBJECTIVE: To determine the prognostic factors for adverse maternal outcomes in women with complete HELLP syndrome. METHODS: A retrospective cohort study was carried out by searching the hospital data for the diagnosis of HELLP syndrome according to Tennessee classification from January 2007 to January 2014. Data included a total of 171 patients between January 2007 and January 2014. The data were collected from the hospital records including demographic data variables, presence of preeclampsia/chronic hypertension, gestational age at the time of diagnosis, and adverse maternal outcomes in terms of eclampsia, disseminated intravascular coagulopathy, acute renal failure (ARF), pulmonary edema, abruptio placentae placental abruption, pleural effusion, ascites, transfusion, and death were determined as adverse maternal outcomes. Independent prognostic factors for each complication with adverse maternal outcome were determined. RESULTS: A total of 171 patients between January 2007 and January 2014 were included in the study. Clinical and laboratory parameters of 171 patients were analyzed. Risk factors for adverse maternal outcomes were as follows; aspartate amino transferase (AST) > 316 U/L, alanine aminotransferase (ALT) > 217 U/L, total bilirubin >2.0 mg/dL, lactate dehydrogenase (LDH) > 1290 U/L, blood urea nitrogen (BUN) > 44 mg/dL, and low platelets (<50,000/mm3). The risk of eclampsia increased 4.1 times and 3.4 times in the presence of LDH >1290 U/L and headache, respectively. Younger maternal age also increased the risk of eclampsia. Risk of ARF increased 15 times at the levels of bilirubin >2.0. CONCLUSIONS: Younger age, headache, bilirubin >2.0 mg/dL, LDH >1290 U/L, and low platelets (<50,000/mm3) were independent prognostic risk factors for predicting adverse maternal outcomes.

Factor XII (Hageman) levels in women with recurrent pregnancy loss.

OBJECTIVE: To evaluate factor XII levels in women with recurrent pregnancy loss (RPL) in a tertiary referral hospital. METHODS: Women who were referred to our hospital for two consecutive abortions or three abortions in between 2007 and 2013 were included in this retrospective observational study. Women were further grouped according to factor XII levels, as <60% and ≥ 60%. RESULTS: Mean factor XII level was 109.1 ± 35.7% (range: 9-200). Ninety-three (7.4%) women had factor XII levels < 60%. Mean factor XII level was 44.8 ± 13.1, and levels ranged between 9 and 60 in this group. Only one woman had factor XII level < 10 %. Remaining 1164 (92.6%) women had factor XII levels ≥ 60%. Mean factor XII level was 114.3 ± 31.7, and levels ranged between 60.3 and 200 in this group, while 1015 (72.4%) women had factor XII levels within the normal range (60%-150% [100% = 30 µg/mL]). CONCLUSION: Decreased activity of F-XII was diagnosed in 7.4% of women with RPL. We concluded factor XII deficiency that might be a rare but significant factor for RPL, and should be evaluated in women who are investigated for recurrent pregnancy loss.

Can maternal serum C-reactive protein levels predict successful labour induction with intravenous oxytocin in term pregnancies complicated with premature rupture of the membranes? A cross-sectional study.

OBJECTIVE: High sensitive C-reactive protein (hs-CRP) is a serum marker for acute inflammation and/or infection. The diagnostic value of serum levels of this protein has been investigated among patients with preterm delivery, premature rupture of the membranes (PROM) and preeclampsia. In this study, the predictive value of hs-CRP for successful labour induction in patients with PROM has been evaluated. MATERIAL AND METHODS: Eighty-six term pregnant patients who experienced pre-labour amniotic membrane rupture from 37-41 weeks of gestation were selected for the study. Maternal serum hs-CRP levels were determined upon admission to the delivery unit and low dose intravenous oxytocin infusion was started to induce labour. The mode of delivery and time interval from labour induction to delivery were the primary endpoints of the study. RESULTS: Twenty-five (29%) out of 86 patients had delivered by caesarean section, while the remaining 61 (71%) had delivered vaginally. The receiver operator characteristic (ROC) curve for testing the significance of higher hs-CRP values and lower probability of vaginal delivery revealed that higher hs-CRP values were found to be insignificant for predicting the need for caesarean section. No statistically significant correlation between high serum hs-CRP levels and the probability of caesarean delivery has been established (Spearman rho:-.126; p=0.24). The mean maternal serum hs-CRP levels during PROM were found to be similar between vaginal and abdominal deliveries. CONCLUSION: Hs-CRP, as an inflammatory marker, was found to be neither specific nor sensitive for the prediction of successful labour induction in term pregnancies with pre-labour rupture of the membranes.

The relationship between third trimester maternal hemoglobin and birth weight/length; results from the tertiary center in Turkey.

OBJECTIVE: The aim of this study was to investigate the relationship between third trimester maternal hemoglobin values and fetal birth weight/length. METHODS: Retrospective study was conducted on 28600 Turkish pregnant women who delivered between January 2010 and December 2011. Hemoglobin values at third trimester, all birth weights/lengths of newborns were retrospectively analyzed. Maternal third trimester hemoglobin values and birth weights/lengths were compared and correlated. RESULTS: The high hemoglobin concentrations at third trimester were associated with high birth weight (odds ratio 1.08; 95% confidence interval 1.05-1.11; p=0.00) and significant positive correlation was determined between maternal third trimester hemoglobin and birth weights/lengths (p=0.00). Low hemoglobin was associated with low length of newborns (p=0.00). CONCLUSIONS: The low hemoglobin values at third trimester gestation were associated with low birth weight and length in Turkish women. The anemia can be a direct cause of deterioration of in utero fetal growth due to lack of oxygen flow to placental tissue or can be an indirect indicator of maternal nutrition deficit. In both circumstances this study reveals that treatment of anemia is directly correlated with better fetal outcomes.

Hepcidin and erythropoietin measurements in the cord blood of neonates with meconium-stained amniotic fluid.

AIM: To compare hepcidin and erythropoietin levels in the cord blood of neonates with meconium-stained amniotic fluid (MSAF) to levels obtained from age-, body mass index- and gravidity-matched neonates with clear amniotic fluid. METHODS: A cross-sectional controlled study was conducted in secondary and tertiary care centers. Cord blood samples of 40 neonates following term gestations (≥37 weeks' gestation) with MSAF and 40 maternal age-, body mass index- and gravidity-matched controls with clear amniotic fluid were analyzed in this study. Demographic data, delivery outcomes and laboratory evaluations were recorded. RESULTS: Cord blood pH levels were lower in fetuses with MSAF when compared to those with clear amniotic fluid (P=0.0001). Fetuses with MSAF had higher cord blood erythropoietin levels in comparison to those with clear amniotic fluid (P=0.0001). Delivery outcomes and hepcidin measurements were similar in both groups. CONCLUSIONS: We demonstrated a significant relationship between erythropoietin levels and meconium passage, but failed to show the existence of a relationship between hepcidin levels and meconium passage.

Umbilical artery intima-media and wall thickness in infants of diabetic mothers.

BACKGROUND: Large for gestational age (LAG) neonates who had been exposed to an intrauterine environment of either diabetes or maternal obesity are at increased risk of developing the metabolic syndrome. This can be explained by exposure to high glucose and insulin levels in utero which alter fetal adaptation and programming. OBJECTIVES: The aim of the study was to evaluate the onset of preclinical atherosclerosis in utero. METHODS: We measured umbilical artery wall thickness (ruWT) in the third trimester by obstetric ultrasound and umbilical artery intima-media thickness (uIMT) in pathologic specimens of umbilical cords obtained shortly after delivery and investigated the relation between these measurements and serum insulin level and C-peptide level in cord blood and assessed insulin resistance with the homeostasis model assessment of insulin resistance (HOMA-IR) in infants of diabetic mothers (IDMs), i.e. the study group, which was divided into a large for gestational age group (LGA)-IDM group and an appropriate for gestational age group (AGA)-IDM group and compared with a control group. RESULTS: The LGA-IDM group had significantly higher insulin (p < 0.001), C-peptide (p = 0.018) and HOMA-IR levels (p < 0.001) compared with the AGA-IDM and control groups. The LGA-IDM group had significantly larger ruWT (p = 0.013) and uIMT (p < 0.001) compared with the AGA-IDM and the control groups. The LGA-IDM group had increased uIMT and ruWT that correlated with the severity of maternal hyperglycemia. CONCLUSIONS: Measurement of ruWT in the third trimester is feasible, reproducible and strongly correlated with pathological serum insulin, C-peptide in cord blood and HOMA-IR levels.

L-arginine pathway in neonates with meconium-stained amniotic fluid.

OBJECTIVE: To study the arginase, nitric oxide synthase and nitric oxide pathways associated with passage of meconium. STUDY DESIGN: Cord blood samples were collected from 20 newborns with meconium-stained amniotic fluid (MSAF) and from 23 newborns with clear amniotic fluid. Cord blood pH, arginase, nitric oxide synthase and nitric oxide levels were compared between the groups. RESULT: The differences between the arginase and nitric oxide measurements of the newborns with MSAF and those with clear amniotic fluid were significant. In the MSAF group arginase levels were significantly lower (p=0.007) and nitric oxide levels were significantly higher (p=0.032) than the clear amniotic fluid group. CONCLUSION: Hypoxia may be involved in the pathogenesis of meconium passage due to decreased arginase and increased nitric oxide levels.

Leukocytosis might precede in-hospital eclampsia in preeclamptic women who do not receive magnesium sulfate.

In an effort to better define preeclamptic women at risk of eclampsia, we examined the predictive value of maternal demographic characteristics and admission maternal laboratory values for the risk of subsequent development of eclampsia in preeclamptic women, who were not receiving magnesium sulfate during hospitalization. The decision to use magnesium sulfate prophylaxis was at the discretion of the treating physician. Preeclamptic women admitted throughout a 3-year period and treated with a protocol exempting magnesium sulfate therapy were retrospectively included (n=497). Maternal data at admission were recorded and analyzed. Eight women developed an eclamptic seizure during subsequent hospital follow-up. Logistic regression models were used to assess the independent predictive role of each variable on the development of eclampsia. Lower serum fibrinogen values, increased leukocyte counts, and increased diastolic blood pressure at admission were independent predictors of a subsequent in-hospital eclamptic seizure. An initial diastolic blood pressure >or=120 mm Hg, blood leukocyte count >16,000/microL, and serum fibrinogen value <450 mg/dL were associated with a 25.4-, 7.1-, and 26.6-fold increased risk of eclampsia, respectively. We conclude that marked leukocytosis and diastolic blood pressure increment might precede the development of eclampsia. Serum fibrinogen concentrations >450 mg/dL seem to be protective for eclampsia. The association between inflammation and eclampsia merits further investigation.

Maternal deaths and their causes in Ankara, Turkey, 1982-2001.

This study was carried out to determine the incidence and causes of maternal deaths about a 20-year period at the Zekai Tahir Burak Women's Health Education and Research Hospital (ZTBWHERH), Ankara, Turkey. All maternal deaths from January 1982 to July 2001 were reviewed and classified retrospectively. Using a computer-generated list, 348 patients admitted to the Labour Department of ZTBWHERH during 1982-2001 were selected as controls. Medical records were reviewed for demographic data, history of antenatal care, route of delivery, referral history, and perinatal mortality. Cases and controls were compared, and standard tests were used for calculating odds ratio (OR) and 95% confidence interval (CI) for the association of demographic and delivery characteristics. During this period, there were 174 maternal deaths and 430,559 livebirths, giving a maternal mortality ratio of 40.4/100,000 livebirths. The mortality rate declined from 85.1/100,000 in 1982 to 11.6/100,000 in 2001. One hundred thirty (74.7%) deaths were due to direct obstetric causes and 24 (13.7%) were abortion-related, while 20 (11.4%) were due to indirect obstetric causes. The most common cause of direct obstetric deaths was pre-eclampsia/eclampsia, followed by obstetric haemorrhage and embolism. Abortion-related sepsis and haemorrhage, anesthesia-related deaths, obstetric sepsis, acute fatty liver of pregnancy, and ectopic pregnancy accounted for other causes of deaths. Cardiovascular disease was the leading indirect cause of death. Referral, lack of antenatal care, and foetal death at admittance were associated with 8-, 3-, and 6-fold increased risk of maternal mortality respectively (OR 8.89, 95% CI 5.7-13.8; OR 3.74, 95% CI 2.5-5.5; OR 6.38, 95% CI 3.1-13.1). Although maternal mortality ratios have declined at the hospital, especially in the past five years, the rate is still high, and further improvements are needed. The problem of maternal mortality remains multifactorial. Short-term objectives should be focused on improving both medical and administrative practices. Improving the status of women will necessarily remain a long-term objective.