背景:产科出血仍然是全球孕产妇死亡的主要可预防原因。在法国,子宫收缩乏力对出血相关孕产妇死亡率的贡献有所下降,而据报道,剖宫产期间手术损伤等其他原因引起的产科出血的贡献有所增加。然而,关于死于这种出血原因的妇女的危险因素和护理过程的证据很少。因此,我们的目的是描述临床概况,潜在机制,剖宫产术中因手术损伤而死于产科出血的妇女的可预防性因素。
方法:在2007年至2018年期间,通过全国永久性增强孕产妇死亡率监测系统(ENCMM)对法国剖宫产期间因手术损伤导致的所有出血相关孕产妇死亡进行了全国分析。我们描述了女性的特点,分娩医院,出血的情况,产科和复苏/输血护理的特点,和主要的预防性因素。
结果:在2007年至2018年期间,法国与出血相关的孕产妇死亡率从2007年的1.6/10万活产(95%CI1.1-2.2)(39/2472650)下降到2016年至2018年的0.8/10万活产(95%CI0.5-1.3)(19/2311783)。剖宫产期间手术损伤导致的与出血相关的孕产妇死亡率从0.08(95%CI0.01-0.3)(2/2472650)增加到0.2(95%CI0.07-0.5)(5/2311783)每100000例活产。在12年的研究期间,在剖宫产手术中死亡的18名妇女中,我们报告了肥胖的高患病率(67%,12/18),先前的剖宫产(72%,13/18),和第二阶段剖腹产(56%,10/18).22%(4/18)剖腹产是在一家每年分娩<1000的医院进行的,没有血库(39%,7/18)或没有成人重症监护(44%,8/18)现场。死亡的总体可预防性为94%(17/18)。主要可预防性因素与出血诊断延迟有关(77%,14/18)由于对异常参数的识别较晚(33%,6/18)和晚期床边超声(56%,10/18),以及由于手术技能不足而导致的管理延误(56%,10/18).
结论:在法国,剖宫产术中的手术损伤越来越多,在很大程度上是可预防的,导致与出血相关的孕产妇死亡,因为其他致命性出血的原因已经变得不那么频繁了。这些女性的特征显示肥胖的患病率很高,先前的剖宫产,二期剖宫产,在医疗和外科资源有限的医院分娩,这表明了致命结果的解释机制和预防机会。
BACKGROUND: Obstetric hemorrhage remains a largely preventable cause of maternal mortality globally. The contribution of uterine atony to hemorrhage-related maternal mortality has decreased in France, while the contribution of other causes of obstetric hemorrhage such as surgical injury during cesarean has been reported to increase. However, little evidence exists regarding the risk factors and care processes of women who died from this cause of hemorrhage. Therefore, we aimed to describe the clinical profile, underlying mechanisms, and preventability factors among women who died from obstetric hemorrhage by surgical injury during cesarean section.
METHODS: Nationwide analysis of all hemorrhage-related maternal deaths by surgical injury during cesarean in France identified by the nationwide permanent enhanced maternal mortality surveillance system (ENCMM) between 2007 and 2018. We described the characteristics of the women, delivery hospitals, circumstances of hemorrhage, features of obstetric and resuscitation/transfusion care, and main preventability factors.
RESULTS: Between 2007 and 2018, hemorrhage-related maternal mortality in France decreased from 1.6/100 000 live births (95% CI 1.1-2.2) (39/2 472 650) in 2007-2009 to 0.8/100 000 live births (95% CI 0.5-1.3) (19/2 311 783) in 2016-2018. Hemorrhage-related maternal mortality ratio due to surgical injury during cesarean increased from 0.08 (95% CI 0.01-0.3) (2/2 472 650) to 0.2 (95% CI 0.07-0.5) (5/2 311 783) per 100 000 live births. Among the 18 women who died from surgical injury during cesarean over the 12-year study period, we report a high prevalence of obesity (67%, 12/18), previous cesarean (72%, 13/18), and second-stage cesareans (56%, 10/18). In 22% (4/18), cesarean section was performed in a hospital providing <1000 births annually, with no blood bank (39%, 7/18) or no adult intensive care (44%, 8/18) on-site. Overall preventability of deaths was 94% (17/18). Main preventability factors were related to delay in hemorrhage diagnosis (77%, 14/18) due to late recognition of abnormal parameters (33%, 6/18) and late bedside ultrasound (56%, 10/18), and delay in management due to insufficient surgical skills (56%, 10/18).
CONCLUSIONS: In France, surgical injury during cesarean section is an increasing, largely preventable contributor to hemorrhage-related maternal mortality, as other causes of fatal hemorrhage have become less frequent. The profile of these women showed a high prevalence of obesity, previous cesarean, second-stage cesarean, and delivery in hospitals with limited medical and surgical resources, which suggests explanatory mechanisms for the fatal outcome and opportunities for prevention.