Trombos under graviditetmortalitet SFOG-veckan Luleå 2007 Eva Samuelsson, distriktsläkare, docent Allmänmedicin, Inst för folkhälsa och klinisk medicin, Umeå universitet
Pulmonary embolism is the leading cause of maternal mortality in countries with low maternal mortality Högberg 1994, de Swiet 2000, Tuffnell 2003, Atrash 1990 -Venous thrombo embolism (VTE) -Amniotic fluid embolism (AFE)
Causes of death in women 15-44 years, 1990-1999 Pulmonary embolism Cancer Accident Suicide Murder Other
Causes of death in women 15-44 years, 1990-1999 33% cancer 12% p-piller 4% graviditet
Pregnancy-related deaths due to pulmonary embolism in Sweden Eva Samuelsson, Margareta Hellgren, Ulf Högberg Acta Obstet et Gynecol. 2007; 86:435-443
AIMS to identify women who died from pregnancy related pulmonary embolism during 1990-99 to study contributive risk factors to describe the trends of mortality from pulmonary embolism during three decades in Sweden.
Kvinna >40 som invandrat från afrikanskt land. Multipara. Överviktig, ej rökare. Gravid v 8 med blödningar och nedre buksmärtor sedan 10 dagar. Inrem akut till gyn, bedöms som missed abortion och får komma dagen efter för exeres. Ingen tolk tillgänglig vid anestesibedömning. Sövd under VE, vaknar till och mår bra. I samband med toalettbesök innan hemgång svimning, tackycardi, dyspné, hjärtstillestånd. Obduktion visar massiv lungemboli+trombos ben.
Kvinna runt 30 år. Normalviktig, ickerökare. Tid frisk frånsett mjältextirpation efter trauma. Planerat snitt v 37 duplex. Op-tid 40 min, spinal-epidural, 400 ml blödning.ej trombosprofylax. 8 dagar pp andfådd, pos lungscint, beh med heparin-waran, avlider dagen därpå
Method (1) Women aged 15 to 44 years who had died during 1990-99 with VTE or AFE as underlying or contributory cause of death were identified from the Swedish Cause of Death Registry (CDR) Women with fatal VTE occurring during pregnancy or within six weeks of terminated pregnancy (maternal death ICD 9, 10), were included in the present study
Method (2) Swedish Cause of Death Registry 236 Non-cancer VTE deaths 158 Medical records 780 contacts VTE deaths representing the refined mortality 120 Excluded Cancer as underlying cause 78 Terminal illness 18 Unconfirmed VTE 7 Embolism with foreign mat 6 Active cancer 7
Deaths from pregnancy related pulmonary embolism during 1990-9 Venous thromboembolism Number Mortality rate per 100 000 live births (95% CI) 10 1.0 (0.5-1.8) Amniotic fluid embolism 5 0.5 (0.2-1.1)
Pregnancy-related deaths from VTE during 1990-1999 (N=10) Age group 15-24 25-34 35-44 2 5 3 Parity 0 2 1 2 >1 5 Unknown 1 Time of event First Second Third Postpartum 5 1 1 3
Previous VTE and heredity as risk factors None of the women who died from pregnancy-related VTE had a history of previous thrombosis There was no information on family history in the records and none had been tested for thrombophilia
Contributive factors for VTE Surgery(no thromboprophylaxis) Caesarian section 3 Laparotomy-scopy 1 Exeresis 1 Overweight/obesity 6 Preeclampsi 1 Concomitant disease 2 Varicose veins 2 Number Language difficulties 2 Doctor s delay 3-4
Deaths from VTE and AFE in Sweden 1971-1999 per 100 000 live births Death 1971-80 1981-9 1990-9 Cause No Rate No Rate No Rate VTE 10 0.97 [0.46-1.78] 7 0.80 [0.32-1.64] 4* 0.38 [0.1-0.97] AFE 10 0.97 [0.46-1.78] 10 1.14 [0.55-2.10] 5 0.48 [ 0.15-1.11] *The six cases of VTE<21 gestational weeks are excluded
Case fatality rate of VTE during pregnancy >28 weeks and/or a registered birth Time period 1973-1980 Incident cases of VTE (No) Fatal cases of VTE (No) 154 10 4.5 Case fatality rate (%) 1981-1989 1990-1999 272 7 3.7 673 4 0.6
What is known in the official statistics? Only five of ten VTE deaths were diagnosed with a pregnancy code. One of these was correctly reported as VTE death in the official maternal mortality statistics (underlying cause of death). In early pregnancy, only two of five deaths were diagnosed with a pregnancy related code.
Exempel I detta fall inget om graviditet på dödsbeviset och följaktligen ej inkluderad i mödra-dödlighetsstatistik. LÄKARENS UTLÅTANDE OM DÖDSORSAKEN Det sjukdoms- eller skadeförlopp som lett till döden A. Den terminala dödsorsaken var Blodproppar i lungpulsådern B. som var en följd av C. som i sin tur var en följd av D. som i sin tur var en följd av Andra sjukdomar och skador som bidragit till dödsfallet
Exempel I detta fall blev lungemboli inte registrerat som underliggande dödsorsak. Den dödsorsak som registreras som underliggande är den som står underst. LÄKARENS UTLÅTANDE OM DÖDSORSAKEN Det sjukdoms- eller skadeförlopp som lett till döden A. Den terminala dödsorsaken var B. som var en följd av C. som i sin tur var en följd av Lungemboli Akut sectio Hotande fosterasfyxi D. som i sin tur var en följd av Andra sjukdomar och skador som bidragit till dödsfallet
CONCLUSIONS Mortality from pregnancy- related PE in Sweden is in the lowest range ever reported There was a possible downgoing mortality trend with a shift towards early pregnancy Death certificate quality must improve Routinely linkage of registers