Audit of Early and Late Maternal Deaths in Georgia: Potential for Improving Substandard Obstetric Care

Figures & data

Figure 1 Maternal death identification and coding, Georgia, 2012.

Figure 2 Causes of maternal deaths by time of death, Georgia, 2012.

Table 1 Selected Characteristics of 23 Maternal Deaths by Main Cause of Death (in Columns), Georgia, 2012

Characteristics	Sepsis/Septic Shock (n=6)	Obstetric Hemorrhage (n=3)	Embolism (n=3)	Preeclampsia/Eclampsia (n=2)	Other Direct (n=3)	Indirect (n=6)	All (n=23)
Age, years
21–30	4	1	2		2	3	12
31–40	2	1	1	1		2	7
≧40		1		1	1	1	4
Delivery mode
Miscarriage/ectopic pregnancy	1	2				1	4
Induced abortion	1					1	2
Vaginal delivery	1	1	1			1	4
Caesarean delivery	3		2		1	2	8
Undelivered/pregnant				2	2	1	5
Time of death
Antepartum				2	2	1	5
Post-abortion	2	2				2	6
Postpartum	4	1	3		1	3	12

Figure 3 Evaluation of care provided to 23 deceased women by key characteristics, Georgia, 2012.

Table 2 Individual Overview of Maternal Deaths (n=23), Georgia, 2012

Case #	Timing of Death	Brief History*	Cause of Death	Timely Recognition	Appr. Management	Timely Treatment	Appr. Referral	Quality of Care**
1	Early Maternal	31–40 years old, P1. Admitted to hospital at 18 GW, incomplete abortion. Self-administration of 10 tablets of Misoprostol (Cytotec©) to terminate pregnancy. Refused hospitalization, later due to aggravation of clinical condition, self-referred to the hospital. Curettage of uterine cavity 15 minutes after admission; antibiotics and saline infusion initiated. Developed septic shock, resuscitation started, hysterectomy performed. Condition deteriorated rapidly during the surgery, and she died.	Sepsis/septic shock	No	No	No	No	3
2	Early Maternal	21–30 years old, P0. Admitted to maternity hospital: 39 GW, severe preeclampsia, obesity, uterine fibroids, intrauterine fetal growth restriction, cephalic presentation, in the first stage of labor. CS performed 7 hours after admission upon woman’s request. Discharged on the 4^th day after delivery in satisfactory condition. On the 5^th day after delivery, sudden death at home.	Embolism	No	No	No	Yes	3
3	Early Maternal	≥ 40 years old, P2. Admitted to hospital at 14 GW, incomplete abortion. Curettage of the uterine cavity. Postoperative hemorrhage - suspected uterus perforation. Saline infusion started. Woman transported to the district hospital. At admission acceptable circulation, mentally altered, Hb-52 g/L, Ht-7.6%. Total hysterectomy performed 20 minutes after admission. Infusion with 9000 mL Crystalloids, 2 packs of fresh-frozen plasma. At the end of the surgery: Hb-36g/L, Ht-3.5%. Woman died despite resuscitation performed.	Obstetric hemorrhage	Yes	No	No	No	3
4	Early Maternal	21–30 years old, P0. Admitted to maternity hospital: 38 GW, cephalic presentation, first stage of labor, pre-labor rupture of membranes. CS performed 50 minutes after admission upon woman’s request. Antibiotic therapy initiated immediately after CS. Two days postpartum fever, no laboratory tests performed, antibiotic therapy continued. On day five fever persisted, laboratory tests performed, antibiotic regimen changed. Septic shock developed on day eight; patient died shortly after the shock.	Sepsis/septic shock	No	No	No	No	3
5	Early Maternal	31–40 years-old, P2. Admitted to hospital at 18 GW, spontaneous abortion. Treatment initiated with Oxytocin, macerated fetus spontaneously delivered. Curettage of the uterine cavity performed, bleeding started during the procedure. 10 IU of Oxytocin administered I/M. Bleeding continued. Transfusion of saline solution along with 20 IU Oxytocin. Fresh and frozen plasma transfused. Bleeding continued, hysterectomy performed after 5 hours. Post-operatively condition deteriorated, despite resuscitation measures died 12 hours post-surgery.	Obstetric hemorrhage	No	No	No	No	3
6	Early Maternal	≥ 40 years old, P4. Admitted to maternity hospital at 32 GW, essential hypertension. At admission: blood pressure (BP) 200/120 mmHg, proteinuria +2. No other laboratory tests performed. Bolus dose of Magnesium sulfate therapy started. One hour after Magnesium Sulphate injection, condition worsened. Overdose suspected. Patient died despite resuscitation measures.	Preeclampsia	No	No	No	Yes	3
7	Early Maternal	21–30 years old, P1. Admitted to maternity hospital at 39 GW, fetus in cephalic presentation, first stage of labor. Elective CS performed. Postoperative period uncomplicated. Discharged home in satisfactory condition. Re-admitted to hospital on day 5 after discharge with fever: 38.9°C, Pulse-124. Blood tests and abdominal ultrasound performed. Peritonitis diagnosed. Antibiotic therapy started. Hysterectomy performed. After the surgery, condition deteriorated further; she died 2 days later.	Sepsis/septic shock	No	No	No	No	3
8	Early Maternal	21–30 years old, P1. Admitted to maternity hospital at 16 GW, spontaneous abortion, fever 39°C; cervical dilatation. Fetus expulsed, curettage of uterine cavity performed. Antibiotic therapy initiated. After curettage condition worsened, septic shock diagnosed, and resuscitation initiated. Two days later the patient died.	Sepsis/septic shock	No	No	No	No	3
9	Early Maternal	31–40 years old, P3 Admitted postpartum to maternity hospital with fever (39°C). On day 9 after CS, discharged home, despite fever. Ultrasound examination performed, no laboratory tests. Antibiotic therapy prescribed and patient discharged home. Woman’s condition worsened, re-admitted to hospital 8 days after discharge. Blood and urine tests performed, surgical site infection suspected; wound drainage conducted, but condition worsened further. Hysterectomy performed; the patient died shortly thereafter.	Sepsis/septic shock	No	No	No	No	3
10	Early Maternal	31–40 years old, P2. Self-referral at 33 GW to outpatient clinic with difficulty breathing and chest pain. BP 200/110 mmHg, no laboratory tests performed. Woman referred to district hospital within 1-hour after admission, condition deteriorated, and died despite resuscitation measures.	Preeclampsia/Eclampsia	No	No	No	No	3
11	Early Maternal	21–30 years old, P0. Admitted in active labor, 41 GW, following an uncomplicated pregnancy. Normal progress in labor and delivery of a 4200-gram neonate. After placenta expulsion, 1 hour after delivery the patient developed atonic uterine bleeding. Uterotonics administered: Oxytocin 5 IU bolus dose and 10 IU diluted in 500 mL saline. BP 100/70, pulse 90. Transfusion of crystalloids commenced. After a short pause, the bleeding continued. Hysterectomy and resuscitation measures performed. Woman died shortly after surgery.	Postpartum Hemorrhage	No	No	No	N/A	3
12	Early Maternal	21–30 years old, P0. Admitted at 23–24 GW to referral hospital unconscious. Reportedly woman had not felt fetal movements in a week. IUFD confirmed at the first point of contact, at the district hospital. Antibiotic treatment initiated. Induction of labor. Four hours later, the patient’s condition deteriorated. Pulse 120, BP 90/60, she developed respiratory distress. Woman transported to referral hospital and died shortly afterward.	Complication following intrauterine death.	No	Yes	Yes	No	2
13	Early Maternal	21–30 years old, P0. Elective CS at term. Esophageal intubation, final peri-arrest intubation. The patient suffered a cardiac arrest and died.	Complication of anesthesia/Failed Intubation	No	No	No	Yes	3
14	Early Maternal	>40 years old, multipara. Sudden death at home whilst 8 weeks GA. No autopsy.	Undefined(Sudden death at home)	N/A	N/A	N/A	N/A	N/A
15	Early Maternal	21–30 years old, P0. Admitted at 24 GW to referral hospital in altered mental status, fever, preceding otitis media with outpatient antibiotic treatment. Cranial CT on admission, laboratory tests, and antibiotic treatment initiated, developed coma and died within 24 hours.	Bacterial meningoencephalitis	No	No	No	Yes	3
16	Late Maternal	21–30 years old, P0. Admitted to referral hospital, 54 days postpartum after vaginal delivery, unconscious, transferred from district hospital with diagnosis of septic shock. Two admissions and discharges prior to transfer to referral hospital. Antibiotic therapy, hysterectomy performed in district hospital. Despite resuscitation measures, the woman died three days later.	Sepsis	No	No	No	Yes	3
17	Late Maternal	31–40 years old, P2. Died at home, 133 days after CS.	Embolism	N/A	N/A	N/A	N/A	3
18	Late Maternal	21–30 years old woman, P0. Died at home, 116 days after vaginal delivery.	Embolism	N/A	N/A	N/A	N/A	N/A
19	Late Maternal	21–30 years old, previous parity unknown. Admitted at 8 GW to hospital for vaginal bleeding, incomplete abortion. Vacuum aspiration performed. Re-admitted after 2 days with abdominal pain, ultrasound investigation confirmed ruptured ectopic pregnancy. Surgery performed and discharged from hospital in satisfactory condition. Died 69 days afterwards in intensive care unit treated for leukemia.	Myeloid leukemia	N/A	N/A	N/A	N/A	N/A
20	Late Maternal	21–30 years old woman, P1. Died 46 days after CS, in the ambulance during transfer to hospital. Prior to pregnancy, treatment of active tuberculosis. Three weeks of complaints: shortness of breath and fatigue.	Tuberculosis	No	No	No	N/A	3
21	Late Maternal	31–40 years old. Diagnosed with breast cancer during pregnancy. Initiated treatment after delivery, died in the hospital 186 days postpartum.	Breast cancer	N/A	N/A	N/A	N/A	N/A
22	Late Maternal	Woman ≥ 40-years old, previous parity unknown. Died at home 90 days after an abortion. Curettage performed at 12 weeks of gestation. History of breast cancer treatment. Diagnosed with recurrent breast cancer during pregnancy.	Breast cancer	N/A	N/A	N/A	N/A	N/A
23	Late Maternal	31–40 years old, Previous parity unknown. Died 167 days after vaginal delivery. Committed suicide, no known history or treatment for mental health disorders.	Suicide	No	N/A	N/A	N/A	N/A

Notes: *For the purpose of anonymization, only previous parity (not gravidity) and age categories are provided. **1 – good care; 2 – improvements of care which would have made no difference to the outcome, and 3 – improvements of care which would have made a difference to the outcome.

Notes: *For the purpose of anonymization, only previous parity (not gravidity) and age categories are provided. **1 – good care; 2 – improvements of care which would have made no difference to the outcome, and 3 – improvements of care which would have made a difference to the outcome.

Abbreviations: P0, nulliparous prior to present pregnancy; P1- 1, delivery prior to present pregnancy; CS, cesarean section; GW, gestational weeks; Hb, hemoglobin; Ht, hematocrit; CT, computer tomography; IUFD, intrauterine fetal death; N/A, not available.