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Between 1982 and 1992, 18 cases of pregnancy-related acute renal failure (PR-ARF) were observed (9% of the total number of ARF). Mean age of the women was 32 years (22-40 years). Uterine hemorrhage and preeclampsia/eclampsia were the major causes of ARF, accounting for 61% of the cases. Patchy renal cortical necrosis was suspected in 2 cases whereas signs of disseminated intravascular coagulation (DIC) or microangiopathic hemolytic anemia were present in 6 (33%) and 9 (50%) cases, respectively. Ten women required hemodialysis; and 6 of them, additional plasma exchange sessions. Five patients (28%) died during the acute phase of the illness, mainly due to brain damage, hepatic failure, and sepsis. Among the survivors, a complete (61.5%) or partial recovery (23.1%) was usually seen, but irreversible renal failure was recorded in 2 cases with postpartum hemolytic uremic syndrome (HUS). Short-lasting oligoanuria (< 3 days) represents a good prognostic index. However, the presence of vascular injury (cortical necrosis, HUS) seems to carry a poor prognosis. In conclusion, PR-ARF is still a critical occurrence, associated with serious prognosis for both women and kidneys. So far, the most effective measures remain the careful prevention and the aggressive management of the obstetric complications.
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PMID:Acute renal failure in pregnancy. 829 Jul 7

Sri Lanka's health policy calls for health services to be accessible to all people, which requires appropriate training of physicians, nurses, and paramedicals. Increasing the training and cadre of public health midwives allows Sri Lanka to make free domiciliary and field health services available to all parts of the country. Sri Lanka must adopt realistic measures to improve guidance and supervision of midwives to derive maximum benefits. Sri Lanka first instituted primary health care (PHC) in 1926 (Health Unit at Kalutara). PHC provides 3 stages of maternal and child health care through home and/or clinic visits: prenatal care, trained assistance during delivery, and postpartum care. In most parts of Sri Lanka, 1 family health worker is available for every 3000 people. Yet, maternal mortality is rather high. A UNICEF study shows that family health workers register only about 50% of pregnant women. A lack of personnel to provide maternal health services is a main reason for high maternal mortality. Many medical officers (1979, 52%) have not done an internship in gynecology and obstetrics. Many (1979, 38%) are assigned to peripheral facilities where they practice obstetrics without any help from experienced physicians. They are reluctant to do simple obstetric measures, e.g., removal of a retained placenta. This reluctance keeps some physicians from admitting mothers in labor, so they transfer them to upper-level hospitals. The Postgraduate Institute of Medicine needs to implement courses in obstetrics and gynecology so the district hospitals can have competent obstetricians on staff. The leading causes of maternal death are, in order of frequency, hemorrhage, abortion complications, eclampsia, sepsis, and obstructed labor. Anemia and retained placenta are the reasons for hemorrhage. Insufficient access to life-saving treatment in emergencies is the single most critical weakness in the maternal health care system, indicating a need to establish intensive care units.
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PMID:Changing trends in maternity care in Sri Lanka. 837 90

A community-based incidence case-referent study was undertaken in a rural and an urban setting in Zimbabwe in order to define risk factors associated with maternal deaths at family, community, primary and referral health care levels. Referent subjects were drawn from place or area of delivery for each consecutive maternal death. Using a multiple source confidential reporting network for all maternal deaths, the maternal mortality rate for the rural setting was 168/100,000 live births and that for the urban setting was 85/100,000 live births. A model for interacting factors contributing to maternal mortality was designed. Haemorrhage and abortion sepsis were the major direct causes while malaria was the leading indirect cause in the rural setting. In the urban setting, eclampsia, abortion and puerperal sepsis were the leading causes of maternal deaths. It was found that all situations associated with diminished, or absent social support, that is, being single (Odds Ratio = 4.7, 95% CI = 2.2-9.8) divorced, widowed, one of several wives, cohabiting, or self-supporting carried an increased risk for maternal mortality, especially in the rural area. Income and level of education for index and referent subjects were comparable, probably because of the limited part of the population under study that belonged to a more affluent class. Distribution of cases and referents by religious-affiliation was also comparable. Age > 35 years and parity > 6 were significant risk factors for maternal mortality in the rural setting, whereas bad reproductive history with reported stillbirth or abortion constituted a high risk both in the city and in the rural areas (Odds Ratios 4-6).(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Maternal mortality in rural and urban Zimbabwe: social and reproductive factors in an incident case-referent study. 851 49

We report a female patient presenting with sepsis and multi-organ failure following eclampsia and intrauterine childdeath. In the phase of recovery, the patient developed consciousness disorder and coma characterized by fasciculation, generalized myoclonia and respiratory insufficiency. The clinical picture corresponded to that of Lance Adam's syndrome. A quick change in the composition of body fluids in the polyuric phase of renal insufficiency associated with an antidiuretic hormone deficit was a cause of that disorder. Metabolic dysfunction and hyperexcitability of neurons developed as a result. Hyperexcitability of the caudal part of the medulla oblongata was responsible for the development of myoclonia. Following the correction of that disorder, the patient completely improved.
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PMID:[Disorders of consciousness due to disorders of body fluid composition--case report of a female patient]. 864 63

Teaching in critical obstetric problems should have special interest during residency and thereafter. Obstetric emergencies are relatively rare but may occur at any time. The obstetrician at that moment enters a special area requiring a multidisciplinary approach. From experiences in recent years and study of the literature the following recommendations can be summarized; (1) the need to understand (patho)physiologic changes in pregnancy, (2) cultivation of an anticipative attitude towards conditions with elevated risks, (3) adequate knowledge of diagnostic procedures, (4) the discipline to make a differential diagnosis, (5) experience with monitoring of (fetal and) maternal condition, (6) availability of management protocols for emergencies such as shock, eclampsia, uterine rupture, amniotic fluid embolism, thrombo-embolism, sepsis and diabetic ketoacidosis, (7) awareness of pitfalls with inspection of lesions and assessment of blood loss, (8) awareness that caesarean section without prior stabilization can be a life threatening procedure, (9) practice in life-saving measures such as uterine compression, packing, ligation of vessels, postpartum hysterectomy, (10) teaching of postoperative care, (11) insight into the cascade of events finally leading to multi-organ failure. Obstetric emergencies require a disciplined approach, in which teamwork is the cornerstone.
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PMID:Training in the management of critical problems: teacher's view. 870 48

A community-based survey of maternal deaths in a rural province (Masvingo) and urban area (Harare) of Zimbabwe in 1989-90 revealed a high incidence of avoidable factors, both within and outside the health sector. During the 2-year study period, 109 maternal deaths were identified in Masvingo (168/100,000 live births) and 66 in Harare (85/100,000 live births). In Masvingo, the three leading causes of death were hemorrhage (25%), postabortion sepsis (15%), and puerperal sepsis (13%); in Harare, these causes were eclampsia (26%), postabortion sepsis (23%), and puerperal sepsis (15%). In Masvingo, the locations of maternal deaths included rural hospitals (50%), provincial hospitals (13%), home (13%), and travelling to or between health facilities (11%); all deaths in Harare occurred in central hospitals. One or more avoidable factors were identified for 90% of maternal deaths in Masvingo and 85% of those in Harare; these factors occurred at the community level in 47% and 38% of deaths, respectively. Among patient-related factors, delay in the decision to seek care for symptoms was most widespread (32% of deaths in Masvingo and 28% of those in Harare). Problems of access to transportation from home to health facility were implicated in 28% of deaths in Masvingo and 3% in Harare. Avoidable factors within the health sector were identifiable in 67% of Masvingo deaths and in 70% of Harare deaths. Notable was failure of health personnel to assess the severity of postabortion conditions and puerperal sepsis and initiate aggressive treatment. Recommended, to reduce maternal mortality in Zimbabwe, are community awareness of risk factors for pregnancy and delivery, collective emergency transportation mechanisms, maternity waiting shelters, appropriate obstetric management protocols, more effective identification and treatment of emergency conditions, and liberalization of existing abortion legislation.
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PMID:A community-based investigation of avoidable factors for maternal mortality in Zimbabwe. 898 30

To develop reliable measures of the rate and causes of maternal mortality in south-west Ethiopia, a cross-sectional retrospective study was conducted in Jimma town. During the 5-year study period (September 1986-August 1990), 100 deaths occurred among women 15-49 years of age in the 5832 households from 10 kebeles included in the study. 15 of these deaths were maternal mortalities, for a rate of 4.02/100 live births. The causes of these deaths were sepsis (7 cases), eclampsia (3 cases), abortion (3 cases), and uterine rupture (2 cases). Eight maternal deaths occurred after delivery. Although 13 deaths took place in a health center or hospital, 8 of the 15 women received no antenatal care and 12 were not family planning acceptors. These findings indicate a need for more coordinated maternal health care services in Ethiopian towns as well as rural areas.
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PMID:Community based study on maternal mortality in Jimma town, south western Ethiopia. 909 Sep 1

This study examines the impact of the Maternal-Child Health and Family Planning (MCH-FP) program in the Matlab, Bangladesh. Data were obtained from the Matlab surveillance system for treatment and comparison areas. This study reports the trends in maternal mortality since 1976. The MCH-FP area received extensive services in health and family planning since 1977. Services included trained traditional birth attendants and essential obstetric care from government district hospitals and a large number of private clinics. Geographic ease of access to essential obstetric care varied across the study area. Access was most difficult in the northern sector of the MCH-FP area. Contraception was made available through family welfare centers. Tetanus immunization was introduced in 1979. Door-to-door contraceptive services were provided by 80 female community health workers on a twice-monthly basis. In 1987, a community-based maternity care program was added to existing MCH-FP services in the northern treatment area. The demographic surveillance system began collecting data in 1966. During 1976-93 there were 624 maternal deaths among women aged 15-44 years in Matlab (510/100,000 live births). 72.8% of deaths were due to direct obstetric causes: postpartum hemorrhage, induced abortion, eclampsia, dystocia, and postpartum sepsis. Maternal mortality declined in a fluctuating fashion in both treatment and comparison areas. Direct obstetric mortality declined at about 3% per year. After 1987, direct obstetric mortality declined in the north by almost 50%. After the 1990 program expansion in the south, maternal mortality declined, though not significantly, in the south. Maternal mortality declined in the south comparison area during 1987-89 and stabilized. The comparison area of the north showed no decline.
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PMID:Decline in maternal mortality in Matlab, Bangladesh: a cautionary tale. 973 75

The reasons and course of acute renal failure during pregnancy, labour and puerperium were presented in 30 women treated in Provincial Hospital in Kielce. The most frequent reason was haemorrhage--15 (50%) women, sepsis--10 (33,3%) women and preeclampsia--eclampsia--2(6, 6%) women. 15 women died as the consequence of multiple organ failure. Among 15 women who survived renal function has returned completely in 13 (86, 6%) ones. In remaining 2 (13, 4%) women chronic renal failure persisted.
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PMID:[Acute renal failure during pregnancy, labor and puerperium in women]. 974 88

Safe Motherhood programs have been expanded over the past six years, but funding and evaluation are still insufficient to meet needs in a cost effective manner. Process indicators may be appropriate qualitative and quantitative indicators of how well programs are functioning and of the underlying mechanisms influencing maternal health outcomes. Three important dimensions of the Safe Motherhood Initiative are policy dialogue, improved services, and behavior change. The World Bank/MotherCare Workshop on Guidelines for Safe Motherhood Programming and the World Bank Discussion Paper on Making Motherhood Safe provide guides to action. Many features of the reports are summarized in this paper (a definition of the problem, the lessons learned, essential features of an effective motherhood program, strategies appropriate for specific settings, policy issues, costs of interventions, and measurement of progress). The problems of maternal mortality stem from septic abortion, postpartum hemorrhage, eclampsia, hypertension, obstructed labor, and sepsis/infection. Community-based family planning has been instrumental in rapidly reducing maternal mortality in Bangladesh. Community-based maternity care programs with trained midwives, medical supplies, and a referral system can reduce the risk of dying by 66%. Trained traditional birth attendants alone do not reduce the risk of maternal mortality. Essential, accessible obstetric care has had an impact in Zaire. Community-based maternity waiting homes, referrals, and prenatal screening prevent maternal mortality in Ethiopia. Safe Motherhood begins with a healthy environment (women's status, political commitment, and socioeconomic development), which is influenced by women's health and nutritional status, reproductive and health behavior, and access to family planning and maternal care services. Immediate determinants of maternal mortality are 1) exposure to pregnancy and 2) complications and their management. Important program elements are services, skilled assistance, referrals, and communication.
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PMID:Programming for safe motherhood: a guide to action. 1013 41


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