| Part ?.Changes in clinical characteristics of obstetric critical patients before and after the implementation of "Two-child policy"Background and Objective:Today,maternal morbidity and mortality has been an unprecedented increase globally although pregnancy is not defined as a disease.pregnant women become a unique group of people due to the physiological changes during pregnancy.Compared with non-pregnancy patients,physiological changes in pregnancy make these pregnant women be more vulnerable to life-threatening complications/underlying diseases of medical or surgical disease,and these factors make it more difficult for clinicians to identify.Most of the literature describes severe obstetric patients from an epidemiological point of view.The more common obstetric critical diseases are hypertensive disorders,obstetric hemorrhage,puerperal infection,acute fatty liver of pregnancy,perinatal cardiomyopathy,amniotic fluid embolism and various complications of internal and surgical diseases during pregnancy.However,the morbidity and mortality of obstetrical critically ill patients vary from region to region.And because the data of obstetrical patients transferred to ICU are more detailed,they can to some extent reflect the morbidity and mortality of critically ill obstetrical patients.Therefore,the study of obstetrical patients transferred to ICU may be one of the best methods close to obstetric critical illness surveillance.In addition,ICU has made a great contribution to reducing critical maternal mortality in recent years.However,a large number of women with scarred uterus have been left in the history of high cesarean section rate in recent years,and the "two-child policy" was implemented nation-widly in September 2015,as well as the increase of elderly pregnant women and the application of artificial assisted reproductive technology in China.These women are at greater risk of pregnancy and delivery.The purpose of this study was to explore the changes of clinical indicators for ICU admission and maternal and neonatal outcome before and after the "Two-child policy",so as to find a theoretical basis for reducing maternal morbidity and mortality.Methods:All critically ill obstetric patients transferred to ICU were examined from January 1,2007 to June 30,2009.These critically ill obstetric patients were defined as two groups,Group 1,patient who was transferred to the ICU during the period from January 1,2007 to May 31,2016;Group 2,patient who was transferred to the ICU during the period from June 1,2016 to June 30,2019.Data was collected from medical records,including demographic characteristics and clinical characteristics,indications in ICU admission,severity of illness(APACHE ? score),interventions in ICU,complications/comorbidities during pregnancy,and maternal outcomes.The indexes of these critically ill obstetric patients were analysed and compared between the two groups.The causes of maternal mortality are divided into direct obstetric deaths and indirect obstetric deaths according to the World Health Organization(WHO)2012 Maternal Mortality Disease Code:ICD-10.Results:During the review period,there were 63703 deliveries in our hospital.A total of 540 cases were transferred to ICU in the two groups,including 376 cases in Group 1(340 cases of our institution,36 cases from other hospitals)and 164 cases in Group 2(159 cases of our institution,5 cases from other hospitals).The ICU admission rate of mother in our hospital was 0.78%(499/63 703).Obstetrical factors were the principal reasons for ICU admission.The top five factors were postpartum hemorrhage,hypertensive disorder complicating pregnancy,heart disease,sepsis and acute pancreatitis respectively.Among them,the proportion of patients with postpartum hemorrhage(P=0.02)and acute pancreatitis in pregnancy(P<0.01)was significantly higher in Group 2,but the proportion of patients with sepsis decreased(P=0.04).Compared with Group 1 on the demographic characteristics and clinical characteristics,women were older,had more gravidity,parity,abortions,blood loss,longer ICU stay and total hospital stay(all P<0.05)in Group 2,Also,more interventional arterial embolization and mechanical ventilation was seen in Group 2(all P<0.05).On the causes of postpartum hemorrhage,placental factors leading to postpartum hemorrhage increased and factors of uterine inertia decreased(P<0.05)in Group 2 than that in Group 1.The proportion of gestational diabetes,acute pancreatitis,intrahepatic cholestasis during pregnancy and thyroid problems all increased,but the proportion of HELLP syndrome and congenital heart disease decreased(all P<0.05).During the audit period,there was a total of 13 cases of maternal death,10 cases died of direct obstetric deaths and 3 cases died of indirect obstetric deaths.The maternal mortality rate in our hospital was12.6/100,000 and the maternal near miss rate was 536.9/100,000.Conclusions:During the audit period,reason for ICU admission of critically ill obstetric patients were still mainly obstetric factors,including postpartum hemorrhage,hypertensive disorder,heart disease and sepsis.There was no significant change in maternal death rate and maternal near miss rate,and the main causes of maternal death were complications/complications during pregnancy.Part ?.Clinical Analysis of complete uterine rupture during pregnancy in thirty-three Hospitals in Yunnan ProvinceBackground and Objective:Complete uterine rupture during pregnancy is a rare perinatal complication that is clinically associated with catastrophic maternal and neonatal outcomes.And complete uterine rupture during pregnancy usually results in maternal and fetal death due to major obstetric hemorrhage.However,due to its low incidence,clinicians do not fully understand the risk factors of complete uterine rupture during pregnancy.And previous studies of uterine rupture have been largely clinical reports of small samples conducted over a limited period of time.Internationally,large samples of long-term clinical studies of complete uterine rupture during pregnancy were reported in Saudi Arabia over a period of 20 years(49 cases,incidence 0.04%)and Norway over a period of 42 years(173 cases,incidence 0.013%).In China,the reports of uterine rupture during pregnancy are basically clinical case reports.In addition,international code diagnosis(ICD)have been used in most studies in this area.However,the code does not distinguish them between catastrophic complete uterine rupture and less catastrophic partial uterine rupture.And complete uterine rupture during pregnancy is expected to increase significantly with the increase of cesarean section.Therefore,we need to understand more accurately the risk factors of complete uterine rupture during pregnancy.The purpose of this study was to evaluate the incidence,etiology,clinical characteristics and maternal and fetal outcome of complete uterine rupture during pregnancy in 33 hospitals in Yunnan Province in the past 14 years.Methods:The incidence of complete uterine rupture during pregnancy was investigated in different medical institutions in Yunnan Province from January 2004 to December 2017.The demographic data,delivery characteristics,intraoperative findings,maternal and neonatal outcomes were all collected from case report form,and then they were divided into scar group and carless group according to the history of scarred uterine or not.These data were compared and analyzed,and the mothers and infants who met the follow-up conditions were followed up.Results:There were 105 cases of complete uterine rupture during pregnancy in 33 medical institutions,including 65 cases in scar group and 40 cases in scar-free group.The overall proportion of complete uterine rupture during pregnancy during the survey period was 0.012%.Compared with non-scarred group,the proportion of abnormal pregnancy history,GDM and primary uterine scar rupture was higher in the scar group(P<0.05).However,women with unscarred uterus was older,and uterine rupture was more common in labor because of obstructive dystocia and/or oxytocin augmentation,which resulted in hemorrhagic shock,stillbirth(all P<0.05).The cause of the rupture was mainly caused by the rupture of the previous scar and the location of the rupture was mainly in the lower segment of the uterus in the scarred group.While the rupture of uterus in non-scar group was mainly due to obstructive dystocia and mostly uterine cervical was involved(P<0.05).Neonatal asphyxia rate and NICU transfer rate were higher in the scar group,but stillbirth and early neonatal death were more common in the non-scar group(P<0.05).Among the 105 women,there were 8(7.6%)maternal death(3 cases in scar group,5 cases in carless group),68 fetal death(64.8%)and 13(12.4%)cases of neonatal asphyxia.Among 46 mothers who were successfully followed up,43 cases were not pregnant because of birth control and 3 cases were pregnant again.Among the 3 cases,2 cases were induced abortion in the early stage of accidental pregnancy,1 case was planned pregnancy and delivered successfully by cesarean section at the 38th week of pregnancy,and the outcome of the mother and baby was good.All the 13 children had long-term normal development.Conclusions:The main risk factors of scarred uterine rupture were cesarean section and laparoscopic myomectomy respectively.While the main causes of intact uterine rupture were dystocia caused by abnormal fetal position,multiple pregnancy,abuse of oxytocin,improper intrauterine operation and poor delivery management.The main clinical symptoms of uterine rupture were severe antenatal abdominal pain,abnormal fetal heart,hemorrhagic shock and antenatal vaginal bleeding.More tissue was involved,more blood loss in patients with intact uterine rupture and these patients usually had a worse prognosis due to delayed diagnosis clinically.Part ?.Etiology and Maternal outcome of Perinatal hysterectomy in the past decadesBackground and Objective:Perinatal hysterectomy is closely related to massive obstetrical hemorrhage and mortality.This study reviewed all cases of perinatal hysterectomy in the First affiliated Hospital of Kunming Medical University in the past decade.Our objective is to explore the incidence,risk factors,clinical characteristics,perioperative and intraoperative conditions,complications and outcomes of perioperative hysterectomy.Methods:all patients undergoing hysterectomy in the Department of Obstetrics,the First affiliated Hospital of Kunming Medical University from January 1,2008 to December 31,2018.The patients were divided into two groups:Group of planned hysterectomy and Group of unplanned hysterectomy.Demographic data of parturients,baseline data before operation,mode of anesthesia,variable value during operation,indications of hysterectomy,type of abnormal placenta,admission to ICU and the main intervention in ICU were all collected from medical records.And the main complications related to hysterectomy procedure were also reviewed.According to the type of variates,x2 test,t test or Fisher exact probability method and Mann-Whitney U test were used to compare the variables between the two groups respectively.Results:(1)There was a total of 51152 deliveries during the study period in our hospital,and 133 cases of perinatal hysterectomy were performed including 49 cases in group of planned hysterectomy and 84 cases in group of unplanned hysterectomy.The overall rate of perinatal hysterectomy was 2.6 per 1000 delivery during the study period.Among of them,68.4%of cases had at least one time of previous cesarean section.(2)The timing of perinatal hysterectomy was as follows,54.1%occurred in the process of cesarean section,31.6%happened after cesarean section and 14.3%occurred post vaginal delivery respectively.(3)The main indications of perinatal hysterectomy were abnormal placenta(71.4%),postpartum hemorrhage caused by uterine atony(13.5%)and coagulation dysfunction(5.3%).(4)the risk factors of placental pathology were mainly related to previous cesarean delivery.(5)88.7%of women was to be transferred to ICU post operation.(6)The common complications of perinatal hysterectomy were fever,acute renal injury,bladder injury,infection of the incision and DIC.(7)Of the maternal characteristics,the hemoglobin level of preoperative in group of planned hysterectomy was higher than that in the group of unplanned hysterectomy.However,compared with the group of planned hysterectomy in terms of anesthesia and perioperative management,women in the group unplanned hysterectomy had higher proportion of general anesthesia,longer operation time,more blood loss and more fluid infusion during the operation.While the proportion of using vasopressors was higher,the hemoglobin was lower after operation in the group unplanned hysterectomy.(8)Of the 133 cases,there were three cases died in the end.One case in the group of planned hysterectomy who died of hemorrhagic shock due to scarred uterus and placenta previa complicated with penetrating bladder.The rest two cases in the group of unplanned hysterectomy,one died of uterine rupture and another died of amniotic fluid embolism respectively.Conclusions:The common indications of perinatal hysterectomy are placental pathology,postpartum hemorrhage caused by uterine atony and coagulation dysfunction respectively.The most common risk factor for placental abnormalities is previous cesarean delivery.Compared with group of planned hysterectomy,the perioperative situation was more complicated in group of unplanned hysterectomy.Part ?.The role of shock index in the identification of postpartum hemorrhage and the prediction of adverse eventsBackground and Objective:Maternal deaths due to obstetric hemorrhage has decreased over the past twenty-five years.However,major obstetric hemorrhage is still the main direct obstetric factor leading to maternal mortality.It is reported that the number of maternal deaths caused by obstetric hemorrhage exceeded 80000 in 2015.And the published data shows that the ratio of maternal mortality caused by obstetric hemorrhage is about 29.3%,and the ratio of severe maternal outcomes is about 26.7%,but there are regional differences in these data.The main reason for these data differences is that the current definition of obstetric hemorrhage itself is not unified,or the definition of the criteria itself is imperfect.At the same time,it is also not perfect for the failure of early identification of obstetric hemorrhage and it is not easy to use in some scenarios.For example,in 1990,the World Health Organization(WHO)defined obstetric hemorrhage as follows:estimated volume of blood loss>500ml for vaginal delivery,estimated volume of blood loss>1000ml for cesarean section.However,some studies found that many pregnant with blood loss>500ml do not have any adverse clinical consequences,and some pregnant women still have the risk of clinical adverse consequences even if the volume of blood loss is not too much.In addition,the definition of obstetric hemorrhage by the mode of delivery is puzzling:why a loss of blood to 500mL after vaginal delivery is at risk of clinical adverse consequences for pregnant women.But the amount of blood loss after cesarean section to reach 500mL will not cause any risks of clinical adverse outcome?Therefore,in clinical practice,the accurate assessment of blood loss is always an intractable problem.We should consider the impact of maternal basic health.Because women with better basic health are usually able to bear a certain amount of blood loss without decompensation of vital organ perfusion(usually blood loss>1000mL).In other words,the definition of obstetric hemorrhage takes into account not only the actual amount of blood loss,but also the clinical manifestations of organ perfusion.For example,the patient's vital signs or hemodynamics or some metabolic parameters(acidosis,base deficit,blood lactate).The changes of these parameters can timely remind clinicians of the identification of hemorrhage and preliminary assessment of the degree of maternal blood loss.But clinically,we need to be a timely identification of obstetric hemorrhage,and this indicator should be applicable to all medical scenarios as far as possible,for example,not only for obstetricians,but also for general practitioners,including emergency doctors.The most important is to have the characteristics of simple and fast,easy to use by the bedside.Preliminary evidence suggests that the shock index may be an indicator of these requirements.Although shock index consists of conventional individual vital signs(pulse and systolic blood pressure)to assess the accuracy of hypotension,a simple combination of them may translate conventional clinical parameters into more accurate indicators of hypovolemia.It is named Shock Index(SI).Shock index is calculated by dividing heart rate by systolic blood pressure and can improve the predictive ability of individual clinical vital signs,which helps to early individualize the identification of obstetric hemorrhage.At present,the use of shock index to identify obstetric hemorrhage is in the ascendant internationally,but the domestic study in this area is less and vague.Therefore,we aim to observe and explore the role of shock index in the identification of obstetric hemorrhage and its prediction of maternal events with major obstetric hemorrhage.Methods:8240 cases were selected as a researched subject,excluding cases with multiple pregnancy,hypertension,heart disease,thyroid problems,antenatal bleeding and incomplete data,from January 1 to December 31 in 2016 in the Department of Obstetrics of the first affiliated Hospital of Kunming Medical University.As a result,only 70 patients with cesarean section and postpartum hemorrhage(24 hours postpartum blood loss ? 1000ml)were enrolled as a case group.The case group was matched with a control group including 70 cases with non-postpartum hemorrhage(24 hours postpartum blood loss<1000ml)according to the mode of cesarean section(emergency cesarean section/elective cesarean section)and anesthesia(local anesthesia/general anesthesia).The clinical data of admission and 24 hours postpartum were collected,including demographic characteristics,volume of blood loss within 24 hours postpartum,heart rate of 10 minutes postpartum hemorrhage and 30 minutes,systolic blood pressure of 10 minutes postpartum hemorrhage and 30 minutes,different time SI(SI1 at admission;SI2,postpartum hemorrhage 10min;SI3,postpartum hemorrhage 30min)and adverse events related to the postpartum hemorrhage,including massive blood transfusion,invasive operation and ICU admission.Invasive procedures here include artery embolization by radiology or hysterectomy by abdominal surgery.Statistical differences of each index between the two groups were compared.Spearman correlation analysis was used to explore the correlation between SI and blood loss and transfusion volume,and ROC was used to observe the prediction of blood loss and adverse events by SI.Results:the emergency cesarean section was 46(65.7%)in the observation group and the control group,and 24(34.3%)in the elective cesarean section in both groups.Local anesthesia was 45(64.3%)and general anesthesia was 45(35.7%)in both case group and control group.There was no significant difference in maternal age,number of deliveries,gestational age and pre-pregnancy BMI between the two groups(P>0.05).There was likewise no significant difference in HR,SBP,hemoglobin and SI at admission between the two groups.The overall median and quartile of shock index(SI1)at admission was 0.75(0.68-0.84)in the two groups.SBP of postpartum hemorrhage 10min and 30min in the control group were higher than those in the case group,while the HR of postpartum hemorrhage 10min and 30min in the case group was higher than those in the control group.Compared with control group,volume of blood loss within 24h postpartum,hospitalization stay and ICU admission rate,SI2 and SI3 were all significantly higher in the case group(all P<0.01).In addition,both SI2 and SI3 were all higher than SI1,and SI2 was the highest.Correlation analysis showed that both SI2 and SI3 were positively correlated with volume of blood loss within 24 hours postpartum and blood transfusion.ROC curves indicated that both SI2 and SI3 had a good predictive value for volume of blood loss within 24 hours postpartum,transfusion volume,invasive procedure and postoperative transfer to ICU respectively.Conclusions:Shock index has a good predictive value for the volume of blood loss within 24 hours postpartum,blood transfusion and adverse events in patients with postpartum hemorrhage. |
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