Strategies for the prevention of maternal death from venous thromboembolism clinical recommendations based on current literature.

Venous thromboembolism (VTE) is one of the leading causes of direct maternal deaths. It has been estimated that approximately 50% of these deaths are potentially preventable. The UK Confidential Enquiries into Maternal Deaths and the National Partnership for Maternal Safety have proposed strategies for the prevention of maternal deaths from VTE based on current guideline recommendations. The main strategies include: - Early recognition and comprehensive assessment of risk factors for VTE at different times from the beginning of pregnancy until patient's discharge from hospital. - Appropriate risk stratification using standardized VTE risk assessment tools (e.g. the Royal College Scoring System). - Risk-based antenatal and postnatal heparin thromboprophylaxis adjusting the heparin dosage and the duration of prophylaxis to the individual patient's risk. - Adequate management of heparin prophylaxis before and after delivery. - Preference of universal rather than selective post-cesarean heparin thromboprophylaxis and application of perioperative mechanical prophylaxis. - Avoidance of gaps in the postpartum prescription of heparin. - Good communication and cooperation between primary and secondary care including community midwifery staff in the postpartum period. - Immediate intravenous administration of (unfractionated) heparin, if pulmonary embolism is suspected. - Critical analysis of all thromboembolic events, particularly in association with maternal death to learn from failures and to realize, if and where improvement is needed. Adequate pharmacological thromboprophylaxis has the potential to reduce the risk of VTE by 60-70% in pregnant women at increased risk.

Amniotic fluid embolism: an interdisciplinary challenge: epidemiology, diagnosis and treatment.

BACKGROUND: Amniotic fluid embolism (AFE) is a life-threatening obstetric complication that arises in 2 to 8 of every 100 000 deliveries. With a mortality of 11% to 44%, it is among the leading direct causes of maternal death. This entity is an interdisciplinary challenge because of its presentation with sudden cardiac arrest without any immediately obvious cause, the lack of specific diagnostic tests, the difficulty of establishing the diagnosis and excluding competing diagnoses, and the complex treatment required, including cardio - pulmonary resuscitation. METHOD: We selectively reviewed pertinent literature published from 2000 to May 2013 that was retrieved by a PubMed search. RESULTS: The identified risk factors for AFE are maternal age 35 and above (odds ratio [OR] 1.86), Cesarean section (OR 12.4), placenta previa (OR 10.5), and multiple pregnancy (OR 8.5). AFE is diagnosed on clinical grounds after the exclusion of other causes of acute cardiovascular decompensation during delivery, such as pulmonary thromboembolism or myocardial infarction. Its main clinical features are severe hypotension, arrhythmia, cardiac arrest, pulmonary and neurological manifestations, and profuse bleeding because of disseminated intravascular coagulation and/or hyperfibrinolysis. Its treatment requires immediate, optimal interdisciplinary cooperation. Low-level evidence favors treating women suffering from AFE by securing the airway, adequate oxygenation, circulatory support, and correction of hemostatic disturbances. The sudden, unexplained death of a pregnant woman necessitates a forensic autopsy. The histological or immunohistochemical demonstration of formed amniotic fluid components in the pulmonary bloodflow establishes the diagnosis of AFE. CONCLUSION: AFE has become more common in recent years, for unclear reasons. Rapid diagnosis and immediate interdisciplinary treatment are essential for a good outcome. Establishing evidence-based recommendations for intervention is an important goal for the near future.

Postpartum hemorrhage--update on problems of definitions and diagnosis.

Maternal mortality due to postpartum hemorrhage (PPH) continues to be one of the most important causes of maternal death worldwide. PPH is a significantly underestimated obstetric problem, primarily because a lack of definition and diagnosis. The 'traditional' definition of primary PPH based on quantification of blood loss has several limitations. Notoriously, blood loss is not measured or is significantly underestimated by visual estimation and there are no generally accepted cut-offs limits for estimated blood loss. A definition based on hematocrit change is not clinically useful in an emergency such as PPH, as a fall in hematocrit postpartum shows poor correlation with acute blood loss. The need for erythrocyte transfusion alone to define PPH is also of limited value, as the practice of blood transfusion varies widely. Definitions based on symptoms of hemodynamic instability are problematic, as they are late signs of depleted blood volume and commencing failure of compensatory mechanisms threatening the mother's life. There is thus currently no single, satisfactory definition of primary PPH. Proper and timely diagnosis of PPH should above all include accurate estimation of blood loss before vital signs change. Estimation of blood loss by calibrated bags has been shown to be significantly more accurate than visual estimation at vaginal delivery. Careful monitoring of the mother's vital signs, laboratory tests, in particular coagulation testing, and immediate diagnosis of the cause of PPH are important key factors to reduce maternal morbidity and mortality.

Outpatient induction -- how safe.

There is a world-wide interest in outpatient care. Induction of labor is commonly offered to women with prolonged pregnancy, and evidence from randomized controlled studies suggest that inpatient and outpatient induction achieve comparative maternal and fetal outcomes. However, safety data are very limited. Careful selections of appropriate patients as well as standardized monitoring protocols are essential before outpatient induction can be initiated. Uterine hyperstimulation with fetal heart rate deceleration and other maternal or fetal adverse events are rare but unpredictable. Unrecognized fetal hypoxia due to uterine contractions remains an unsolved problem after discharge from the hospital. The ideal method for outpatient cervical ripening is controversial. The local application of nitric oxide donors prior to induction might be a promising approach. Larger studies are necessary before widespread use of outpatient cervical ripening by prostaglandins or other cervical ripening agents can be advocated.