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P317 Postpartum health care seeking in Iran
Poster presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S413–S729
Methods: It was a retrospective study. Medical records were reviewed and all maternal mortality cases that occurred between January of 1999 and December of 2008 were included in this analysis. Results: During this 10-year period, 36 maternal deaths occurred (0.27%). Infection was the most common cause (18 cases – 50%), followed by hemorrhage (5–13.8%) and thrombosis (5 –-13.8%) cardiopathy 4 (11.1%), hypertension 2 (5.5%), and nephropathy 2 (5.5%). This mortality prevalence has been relatively constant over time. Conclusions: Maternal mortality is a global problem facing all those involved in woman’s care. Strong health systems are needed to analyze the cause for these deaths. Reducing maternal mortality in each community in each country of the world is a sound medical and economical strategy which would benefit every society at large. P315 Successful use of balloon tamponade to control PPH due to vaginal laceration in a Jehovah’s Witness A. Ray1 , S. Phillip2 , J. Llahi3 , W. Yoong4 . 1 North Middlesex University Hospital, Specialist Registrar, 2 Medical Student St George’s University, Grenada, 3 Consultant, North Middle sex University Hospital, 4 Consultant North Middlesex University Hospital A 31 year old Jehovah’s Witness (JW) presented at 41 weeks gestation in spontaneous labour and had a ventouse delivery for prolonged second stage. The episiotomy was repaired but heavy bleeding was noted from tears in the vaginal mucosa. Compressions sutures “cheese-wired” through the friable tissue but the bleeding appeared to abate with firm pressure although this restarted when pressure was released. A Bakri balloon (Cook Ireland Ltd, Limerick, Ireland) was placed in the vagina and inflated with 100 ml of normal saline: this completely stopped the bleeding and was left in-situ for 24 hours, after which it was deflated and removed. The estimated blood loss was 1200 ml and her postnatal Hb was 7.8 g/dl. Discussion: Vaginal lacerations can be associated with significant loss of blood and at least six haemorrhage-associated maternal deaths due to vaginal lacerations were reported [1–4] between 1964 and 1984 in the UK. This is especially important in JWs who already have a 65-fold increased risk of death due to haemorrhage [5]. Our case appears to be the first to describe the use of balloon tamponade to arrest severe bleeding associated with vaginal lacerations in a JW although there have been two previous case reports on the use of vaginal tamponade in vaginal lacerations: 1. Tattersall and Braithwaite [6] (2006) described the use of two Bakri balloons within the vagina to control intractable bleeding in a postnatal patient with perineal lacerations. 2. Condie and colleagues [7](1994) reported a case of non-obstetric vaginal lacerations in a 14 year old girl in whom they inflated a Sangstaken tube within the vagina. Balloon tamponade is easy to insert, produces a more uniform tamponade and the drainage channel helps to estimate blood loss after insertion. This novel use of Bakri balloon for intractable bleeding from vaginal lacerations is well worth disseminating to obstetricians, especially when managing women who decline blood transfusion, as persistent suturing of already friable vaginal mucosa often provokes more bleeding. P316 A comparison of severity-of-illness indices in critically-ill obstetric patients in Colombia J. Rojas Suarez, D. Harrison, E. Ramos Classon, J. Miranda Quintero, J. Fernandez Mercado, F. Diaz Saavedra, A. Oyola Yepes Objective: Determine the utility of general severity-of-illness indices, including APACHE IV, SAPS III, MPM II and the ICNARC model to predict mortality in obstetric patients admitted to
S503
an Intensive Care Unit (ICU) from Cartagena, Colombia. Design: Analysis from a Retrospective database. Setting: ICU Gestion ´ Salud, Cl´ınica Maternidad Rafael Calvo, Cartagena, Colombia, August 2005 to December 2.007. Patients: 162 obstetric critical care admissions. Measurements and Main results: The severity-of-illness indices was evaluated by comparing the mortality predicted by the models to the observed mortality, using APACHE II, APACHE IV, SAPS, SAPS II, SAPS III, MPM, MPM II, MPM III and ICNARC, to evaluate the best risk prediction model in this population. The mortality of the studied group was 7.4%. Mortality was over-estimated by the majority of indices; APACHE II, SAPS, SAPS III and MPM III significantly over-estimated mortality. The most accurate estimate of mortality was from the ICNARC model (SMR 0.97), it shows, close to perfect discrimination (AUROC = 0.998). However, discrimination was excellent (AUROC>0.95) for all models, except MPM, which had extremely poor discrimination. Conclusions: Many models overestimate mortality in the obstetric population. From our results, the ICNARC and MPM II models reflect practical and useful indices for assessing the risk in our obstetric patients, but the small sample size made preclude this conclusion. P317 Postpartum health care seeking in Iran M. Rouhi, H. Usefi, S. Mohamad Alizade. Islamic Azad university, Mahabad branch, Iran Introduction: 6 weeks after delivery changes which is produced in pregnancy recovered but many of unknown morbidity remained and have many effects on daily activity (child care, household responsibilities and employment). Some of mothers don’t reveal this morbidity and health care providers don’t pay attention to this morbidity. For this reasons health problems after childbirth have been called a hidden morbidity. Method: This survey was descriptive that postpartum maternal morbidity and prevalence of depression and fatigue in this period were measured. In this study 1330 mothers who were referred for their baby’s immunization 45 days to health centers in Tabriz, were interview. SPSS/Win was used for all statistical analysis. Results: One or more health problems were reported by 89% of women in the first postnatal. The problem include: backache (52.7%), headache (49.9%), fatigue (44.4%), constipation (26.6%), postpartum blue (24.1%), breast problems (13.6%), and abnormal vaginal discharge (11.1%). Hemorrhoids (10.1%), stitches infection (9.6%), urinary tract infection (9.0%), side effect of anesthesia (7.4%), abnormal vaginal bleeding (5.5%), sexual problems (5.4%), urinary incontinence (2.1%), difficulty voiding (2.8%) and other problems (3.4%). Husband was the most common source for consult. Stitches infection was the only reason for mothers referring to physicians. In rest cases mothers did not referred anywhere. Conclusion: with such a large variety of complications quality and quantity plan care should be assessed. At antenatal care mothers and her family educated about this problem and health care providers should assessed mothers about this problem. P318 Indirect maternal mortality in The Netherlands 1993–2005 J. Schutte1 , L. De Jonge2 , N. Schuitemaker3 , J. Santema4 , E. Steegers5 , J. Van Roosmalen2 . 1 Isala Klinieken, Zwolle, The Netherlands, 2 Leiden University Medical Center, Leiden, The Netherlands, 3 Diaconessen Hospital, Utrecht, The Netherlands, 4 Medical Center Leeuwarden, The Netherlands, 5 Erasmus University Medical Center, Rotterdam, The Netherlands Objectives: To assess the incidence and causes of indirect maternal death and related substandard care factors in The Netherlands. Study design: Data were collected as part of the nationwide Confidential Enquiry into causes of maternal mortality in the period
Methods: It was a retrospective study. Medical records were reviewed and all maternal mortality cases that occurred between January of 1999 and December of 2008 were included in this analysis. Results: During this 10-year period, 36 maternal deaths occurred (0.27%). Infection was the most common cause (18 cases – 50%), followed by hemorrhage (5–13.8%) and thrombosis (5 –-13.8%) cardiopathy 4 (11.1%), hypertension 2 (5.5%), and nephropathy 2 (5.5%). This mortality prevalence has been relatively constant over time. Conclusions: Maternal mortality is a global problem facing all those involved in woman’s care. Strong health systems are needed to analyze the cause for these deaths. Reducing maternal mortality in each community in each country of the world is a sound medical and economical strategy which would benefit every society at large. P315 Successful use of balloon tamponade to control PPH due to vaginal laceration in a Jehovah’s Witness A. Ray1 , S. Phillip2 , J. Llahi3 , W. Yoong4 . 1 North Middlesex University Hospital, Specialist Registrar, 2 Medical Student St George’s University, Grenada, 3 Consultant, North Middle sex University Hospital, 4 Consultant North Middlesex University Hospital A 31 year old Jehovah’s Witness (JW) presented at 41 weeks gestation in spontaneous labour and had a ventouse delivery for prolonged second stage. The episiotomy was repaired but heavy bleeding was noted from tears in the vaginal mucosa. Compressions sutures “cheese-wired” through the friable tissue but the bleeding appeared to abate with firm pressure although this restarted when pressure was released. A Bakri balloon (Cook Ireland Ltd, Limerick, Ireland) was placed in the vagina and inflated with 100 ml of normal saline: this completely stopped the bleeding and was left in-situ for 24 hours, after which it was deflated and removed. The estimated blood loss was 1200 ml and her postnatal Hb was 7.8 g/dl. Discussion: Vaginal lacerations can be associated with significant loss of blood and at least six haemorrhage-associated maternal deaths due to vaginal lacerations were reported [1–4] between 1964 and 1984 in the UK. This is especially important in JWs who already have a 65-fold increased risk of death due to haemorrhage [5]. Our case appears to be the first to describe the use of balloon tamponade to arrest severe bleeding associated with vaginal lacerations in a JW although there have been two previous case reports on the use of vaginal tamponade in vaginal lacerations: 1. Tattersall and Braithwaite [6] (2006) described the use of two Bakri balloons within the vagina to control intractable bleeding in a postnatal patient with perineal lacerations. 2. Condie and colleagues [7](1994) reported a case of non-obstetric vaginal lacerations in a 14 year old girl in whom they inflated a Sangstaken tube within the vagina. Balloon tamponade is easy to insert, produces a more uniform tamponade and the drainage channel helps to estimate blood loss after insertion. This novel use of Bakri balloon for intractable bleeding from vaginal lacerations is well worth disseminating to obstetricians, especially when managing women who decline blood transfusion, as persistent suturing of already friable vaginal mucosa often provokes more bleeding. P316 A comparison of severity-of-illness indices in critically-ill obstetric patients in Colombia J. Rojas Suarez, D. Harrison, E. Ramos Classon, J. Miranda Quintero, J. Fernandez Mercado, F. Diaz Saavedra, A. Oyola Yepes Objective: Determine the utility of general severity-of-illness indices, including APACHE IV, SAPS III, MPM II and the ICNARC model to predict mortality in obstetric patients admitted to
S503
an Intensive Care Unit (ICU) from Cartagena, Colombia. Design: Analysis from a Retrospective database. Setting: ICU Gestion ´ Salud, Cl´ınica Maternidad Rafael Calvo, Cartagena, Colombia, August 2005 to December 2.007. Patients: 162 obstetric critical care admissions. Measurements and Main results: The severity-of-illness indices was evaluated by comparing the mortality predicted by the models to the observed mortality, using APACHE II, APACHE IV, SAPS, SAPS II, SAPS III, MPM, MPM II, MPM III and ICNARC, to evaluate the best risk prediction model in this population. The mortality of the studied group was 7.4%. Mortality was over-estimated by the majority of indices; APACHE II, SAPS, SAPS III and MPM III significantly over-estimated mortality. The most accurate estimate of mortality was from the ICNARC model (SMR 0.97), it shows, close to perfect discrimination (AUROC = 0.998). However, discrimination was excellent (AUROC>0.95) for all models, except MPM, which had extremely poor discrimination. Conclusions: Many models overestimate mortality in the obstetric population. From our results, the ICNARC and MPM II models reflect practical and useful indices for assessing the risk in our obstetric patients, but the small sample size made preclude this conclusion. P317 Postpartum health care seeking in Iran M. Rouhi, H. Usefi, S. Mohamad Alizade. Islamic Azad university, Mahabad branch, Iran Introduction: 6 weeks after delivery changes which is produced in pregnancy recovered but many of unknown morbidity remained and have many effects on daily activity (child care, household responsibilities and employment). Some of mothers don’t reveal this morbidity and health care providers don’t pay attention to this morbidity. For this reasons health problems after childbirth have been called a hidden morbidity. Method: This survey was descriptive that postpartum maternal morbidity and prevalence of depression and fatigue in this period were measured. In this study 1330 mothers who were referred for their baby’s immunization 45 days to health centers in Tabriz, were interview. SPSS/Win was used for all statistical analysis. Results: One or more health problems were reported by 89% of women in the first postnatal. The problem include: backache (52.7%), headache (49.9%), fatigue (44.4%), constipation (26.6%), postpartum blue (24.1%), breast problems (13.6%), and abnormal vaginal discharge (11.1%). Hemorrhoids (10.1%), stitches infection (9.6%), urinary tract infection (9.0%), side effect of anesthesia (7.4%), abnormal vaginal bleeding (5.5%), sexual problems (5.4%), urinary incontinence (2.1%), difficulty voiding (2.8%) and other problems (3.4%). Husband was the most common source for consult. Stitches infection was the only reason for mothers referring to physicians. In rest cases mothers did not referred anywhere. Conclusion: with such a large variety of complications quality and quantity plan care should be assessed. At antenatal care mothers and her family educated about this problem and health care providers should assessed mothers about this problem. P318 Indirect maternal mortality in The Netherlands 1993–2005 J. Schutte1 , L. De Jonge2 , N. Schuitemaker3 , J. Santema4 , E. Steegers5 , J. Van Roosmalen2 . 1 Isala Klinieken, Zwolle, The Netherlands, 2 Leiden University Medical Center, Leiden, The Netherlands, 3 Diaconessen Hospital, Utrecht, The Netherlands, 4 Medical Center Leeuwarden, The Netherlands, 5 Erasmus University Medical Center, Rotterdam, The Netherlands Objectives: To assess the incidence and causes of indirect maternal death and related substandard care factors in The Netherlands. Study design: Data were collected as part of the nationwide Confidential Enquiry into causes of maternal mortality in the period