Koagulopatie - hlavní příčina mateřské úmrtnosti

Coagulopathies - the Main Cause of Maternal Mortality

Objective:
Under the framework of 30-year analysis of maternal mortality in the Czech Republicwe focused on the area which represents a major problem of life-threatening situations in mater-nal morbidity with greatest impact on maternal mortality in current obstetrics. Our aim was toremark on major causative relationships on specific clinical courses of particular maternal deaths,to highlight the major mistakes and errors and to provide basic characteristics and statistics ofparticular risk groups.Design: Retrospective epidemiological study.Setting: 1. Department of Obstetrics and Gynecology of the 1stMedical School of Charles Univer-sity and General University Hospital, Prague 2; 2. Institute for Care of Mother and Child, Prague-Podoli.Methods: We used database of 64 cases of maternal deaths due to thrombembolism (TE) and 89cases of deaths related to disseminated intravascular coagulopathy (DIC) in the Czech Republicduring 1978-1997 to analyze their causes, clinical courses, especially related to obstetrical surge-ry, adequacy of provided care, and characteristics of their occurrence. We analyzed demographiccharacteristics of the period of onset of complications leading to death, age, parity, and place ofdeath.Results: Coagulopathies including TE and DIC account for 42% of “clean” maternal mortality andrepresent a priority in our field. Frequency and risk of cases of death due to TE in 1991-1997decreased substantially after introduction of obligatory microheparine prophylaxis in 1994among pregnant women at risk. There was 1 case of death due to TE per 40,820 live born babies.Cesarean section participated on 41% cases of TE. Situation related to deaths due DIC is veryunsatisfactory. There was 1 case of death per 29,345 live born babies without improving trend inthis group. Analysis by age clearly documents higher risk among older women in both TE and DICgroups. The same trend was observed for parity. Beginning of development of TE and DIC fallsmost frequently into early post-partum period and early puerperium, however 36% of TE occurredduring first and second trimester. We have marked the factors with possible direct relationshipsto deadly complications in both TE and DIC groups. Mistakes and errors were in organization ofcare, in primary and secondary prevention, in incorrect diagnosis, in inappropriate and especial-ly incomplete treatment, and in frequently late surgical intervention.Conclusion: Currently established complex prophylactic measures to prevent development ofthrombembolic complications provide, if fully implemented, possibility to minimize these threate-ning and formerly very frequent situations leading to death. However, there is ongoing danger ofhemorrhagic complications related to the DIC, which despite the modern therapy represent themajor factor in maternal mortality and morbidity.

Key words:
thromboembolism, disseminated intravascular coagulopathy, maternal mortality, ges-tation