There were 131 deaths associated with hypertensive disorders of pregnancy (eclampsia, pre-eclampsia and chronic hypertension). Seventy-seven deaths were associated with eclampsia and the remaining 54 were due to non-eclamptic causes. The major final cause of death due to hypertension in pregnancy was intracranial haemorrhage. Other causes included liver rupture and associated postpartum haemorrhage. Contributory causes included pulmonary oedema, renal failure/ impairment and disseminated intravascular coagulation. Deaths from eclampsia occurred equally at all levels of health care and 4 occurred at private institutions. Deaths from hypertensive disorders other than eclampsia, occurred mainly at level 1 hospitals. Most deaths for eclampsia occurred at low parity (parity 0 = 41%), whilst 12% of deaths in non-eclamptics occurred in women of parity > 5. Similarly, most deaths from eclampsia occurred in women > 19 years, while most in the non-eclamptic group were aged 25 years and greater. The most common avoidable factors were patient-orientated problems in women who presented late for antenatal care or late to hospital when symptomatic. Administrative factors also played a major role, in that there was a delay in referral due to the unavailability of transport and either from the lack of protocols of management or failure to follow clinical protocols of care. Most women presented as an emergency event and failure of resuscitation/ achievement of haemodynamic stabilisation was a significant factor.
Clear protocols for management of hypertension in pregnancy at all levels of care are required.
Key Recommendations:
Health education programmes to promote the necessity for appropriate antenatal care to patients and all health workers.
Protocols for the Management of
hypertension in pregnancy: This should be co-ordinated
at national level (with regional modifications), and
should include:
Management and in specific situations,
viz.
- in ambulances
- while waiting referral;
- "fits" in casualty/emergency departments
- the need for and method of haemodynamic stabilisation.
- Monitoring and observations must be done throughout the pre-, intra- and post-partum periods. In addition investigation of the hepatic, renal, haematological and coagulation systems must be done in appropriate cases. Monitoring and lowering of blood pressure and fluid balance are essential components of management.
Criteria for referral, and the appropriate level of care at which the complications should be managed at, and referral patterns to the appropriate level of care must be established. Issues such as cross-border transfer and co-operation between hospitals must also be addressed.
Continuing Professional Development courses on managing hypertensive disorders in pregnancy to be provided to all staff at all levels of health (including clinic and level 1 facilities), particularly in respect of referrals, problem recognition, and monitoring of women post-delivery.
Creation of a post of a Regional Reproductive Health Advisor/Expert to promote and update protocols of management, carry out staff training at all levels of care and to perform regular audits.
Provide education to the general public in respect to intended and unintended adolescent pregnancies (hidden pregnancies) and information on the availability of termination of pregnancy services.
Deaths from hypertensive disorders of pregnancy (HDP) include deaths from eclampsia, pre-eclampsia (proteinuria hypertension) chronic hypertension, HELLP and liver rupture. Hypertensive disorders were the most common of all primary causes of death reported in South Africa, contributing 23.2% (n = 131) of all deaths. Eclampsia accounted for 77 (58.8%) deaths (Table 3.1). Moreover, hypertensive disorders accounted for 36.6% of all direct obstetric deaths.
The majority of deaths due to HDP were reported from the Provinces of Gauteng, KwaZulu-Natal and Free State. All Provinces however, reported deaths from HDP with Gauteng having the largest number of deaths, both in respect of absolute numbers, and percentage of direct causes of maternal deaths (Table 3.2).
The magnitude of the problem resulting from HDP might be under-reported due to the poor reporting in some Provinces. However, there are adequate data from areas representing rural, peri-urban and urban areas to be able to identify the major problems. These problems are likely to truly reflect the situation throughout the country.
Table 3.4 shows the relation between age and HDP. Most eclamptics were below the age of 30 years (n = 50) and 14 were < 20 years. It should be noted that 20 of the 77 eclamptics were above the age of 30 years, with 2 being over the age of 40 years. Most of the women with proteinuric hypertension were above the age of 25 years.
Hypertension in the age group < 20 years was the most common contributor to the primary obstetric cause of death accounting for 21 of 77 deaths in this age group.
Most eclamptic deaths occurred in women of low parity (Table 3.4); 51 of 77 women with eclampsia being parity 2 or less, and 25 being primigravidae.
Table 3.6 shows the level of health care and hypertension as the primary cause of death. It is important to note that 4 deaths occurred at private institutions. In addition, a large number of deaths occurred at level I and level II health facilities.
Cerebral complications (n = 51) were the commonest organ system involved, followed by pulmonary oedema and acute respiratory arrest in the 131 hypertensive deaths (Table 3.7). Post-mortems were only performed in 2 of the deaths, but a number had CAT scans.
An overall view of possible factors that need attention is shown in Table 3.8-3.10. Patient-orientated problems were mainly related to non-attendance for antenatal care or infrequent attendance. In respect to administrative problems, the lack of trained staff, inadequate communication, communications between health facilities and the absence of referral patterns were evident. In 25% of women dying due to complications of HDP, there was a significant delay in transporting them to hospital or between hospitals. In addition, cross-border communications were inadequate or not put in place. A lack of ICU facilities was evident. This was most apparent in level 3 hospitals with 27% of women, who subsequently died of complications of HDP, required an ICU bed but were denied one or experienced a delay in receiving one.
In general, there was failure to recognise that a patient had a problem (problem recognition failure); incomplete assessment, continued monitoring of abnormalities without action and delay in referral. These avoidable factors all occurred during antenatal care. In addition, there was a failure to institute a plan of management resulting from a lack of protocols of management or failure to utilise protocols. This resulted in a delay in referral and incorrect decisions being made at level II hospitals.
The following case histories illustrate some avoidable factors, missed opportunities and sub-standard care.
Case1: Failure to recognise problem at primary health care clinic: A P2, G3, aged 35 years at 36 weeks gestation, had a blood pressure of 130/100 mmHg detected at a clinic and information was provided. One week later, she again had a blood pressure of 130/100mmHg, proteinuria +, and complained of headache. She was given Panado and asked to return in 1 week. She returned two days later, having had a seizure at 23h00. She was transferred but arrived at a level 2 hospital without an intravenous line and without a urinary catheter, despite advice provided by the referral centre. A medical officer at the level 2 hospital saw her but there was no evidence of decision-making, no intravenous magnesium sulphate was presented and the high blood pressure was not well controlled. The patient was found to be comatose 6 hours later, and died subsequently.
Comment: This case illustrates failure to recognise the problem by primary health care staff and a probable lack of equipment (intravenous lines and urinary catheters) at clinic level. At level 2 care, a specialist or experienced medical officer should see such patients, if available. The medical officer did not recognise severity of situation and did not follow protocol, or did not have one. In addition, no decision as to the management was made. Junior doctors must be provided with protocols of management and must be supervised.
Lessons
Solutions
Case 2: This case illustrates problems of "hidden pregnancies", non-attendance for antenatal care, poor monitoring/observations following delivery, lack of protocols of management and lack of ambulance services: A 21 year old primigravidae had a convulsion at home. The ambulance was phoned but only arrived 36-48 hours later. The patient had apparently not informed her parents of her pregnancy. On arrival at the hospital, she was restless and found to be in labour. Magnesium sulphate was prescribed and she delivered within 2 hours. She was transferred immediately to a lying-in ward without orders or any monitoring, where she was found to be in respiratory distress a few hours later and subsequently died.
Comment: this case illustrates the following problems:
Case 3: A P2, G3 was transferred with a diagnosis of severe pre-eclampsia to a level 2/3 hospital. Pulmonary oedema was missed at the referral hospital. The patient was 30 weeks pregnant and was hypoxic due to her pulmonary oedema. The pulmonary oedema did not respond to conservative treatment and a caesarean section was performed. The patient required intensive care facilities, which were not available.
Comment: This case illustrates 2 features: firstly, that hypertension in pregnancy is associated with pulmonary oedema and a complete physical examination of all organs systems, timeous recognition and early treatment could prevent mortality. Pre-eclampsia must be recognised as a multi-organ/system disorder. Furthermore, transfer of such patients needs appropriate ambulance and staff. Secondly, there is a need for more ICU facilities at level 2/3 facilities. Obstetric patients requiring ICU facilities are mostly young, have a good prognosis and have other children at home. If ICU beds are rationed, obstetric patients should enjoy a high priority.
Case 4: A P1, G2 at 36 weeks gestation was admitted because of a blood pressure of 200/120mmHg and proteinuria to a level 1 hospital. There was no evidence of any decision-making or intensive monitoring or observations. The patient was found to be comatose during the night, and the nursing staff could not get a doctor on call until the following morning.
Comment: This case illustrates administrative and management problems. It is the responsibility of the superintendent of a hospital to ensure doctors are on call and available. In situations where no doctors can be contacted, the nurses should have the authority to transfer patients. However, the initial management of this patient was totally inadequate. Was this due to ignorance or laziness? A severe proteinuric hypertensive at 36 weeks should have had her high blood pressure lowered and baby delivered as a matter urgency.
Hypertensive disorders of pregnancy and their complications were the most common cause of maternal death. This is in keeping with published hospital-based reports from all major centres in the country.
Intracerebral haemorrhage was the most likely cause of death in most cases and probably implies that due attention is not being placed on lowering very high blood pressures. It must be noted that magnesium sulphate is not an antihypertensive agent, consequently, high blood pressure must be lowered and kept at levels of between 90 and 100 diastolic, and 150 and 160 systolic mmHg. More importantly, blood pressure levels must be monitored throughout labour and for at least 24 hours following delivery in a high-care setting. A constant avoidable factor was the lack of monitoring during the antenatal period, labour and particularly, post-delivery. A few patients were also discharged or referred back to a lower level of care too soon. Understanding of the pathophysiology will obviously lead to a more appropriate forms of management, in particular, lowering of high blood pressure and fluid balance.
In relation to maternal age and pre-eclampsia, a significant proportion of the women with eclampsia who died were less than 20 years old and a number of these had not had antenatal care because their pregnancies were "hidden". Contraceptive services, and information on termination of pregnancy services ought to be made freely available and accessible. Eclampsia, however, also occurred in women above the age of 25 years, and 2 patients were in their forties. All health care workers need to note that eclampsia can occur in all age groups.
A surprising finding was the apparent decrease in the number of deaths in women over 34 years of age. The interim report of the NCCEMD pointed out that such women are at particular risk. It might mean that the number of pregnancies in this group is declining. However, women over 34 years are still at greater risk than the general population for dying of complications due to hypertension.
Pre-eclampsia must be recognised as a multi-system disorder. This report highlights this point (Table 3.7). Cardiac failure, respiratory failure, and liver failure were major contributors to deaths. The management of subcapsular haematoma and rupture of the liver in particular, are of great concern. Conservative measures do not seem to work in liver rupture and the only comment that can be made, is for all health workers to be aware of this problem and intervene by termination of pregnancy before the disease gets to a stage of subcapsular haematoma formation or liver rupture. Therefore, all health care workers should be aware of the HELLP syndrome and need to enquire about epigastric pain.
Similarly, it appears that health care workers are not alerted to the early signs of pulmonary oedema. A significant contribution (16.8%) to the final and contributory causes of death was due to pulmonary oedema. Early signs of pulmonary oedema must be sought and appropriate fluid balance measurements instituted and monitored. These patients need a full examination and investigation as some may have a cardiomyopathy.
There was a considerable delay in transporting women between their home and health institutions and between health institutions. This affected 25% of women who subsequently died due to complications of HDP. A system must be put in place that alerts the ambulance services as to what are extremely urgent cases. Complications of HDP must be one of these and should receive priority in transport.
The lack of ICU facilities is again highlighted in this report. Twenty-seven percent of women requiring ICU facilities, who subsequently died or had a delay in receiving an ICU bed, died due to complications of HDP. Where ICU beds are rationed, a method must be created where criteria for admission to ICU are discussed and instituted. Pregnant women are usually young, have a good prognosis and have children at home. They certainly should be high on the priority list if ICU beds are rationed.
In general, much work needs to be done if we are to decrease deaths from hypertension in pregnancy as there are a large percentage of deaths due to substandard care, avoidable factors and missed opportunities. Appropriate antenatal care must be provided: emphasis must be placed on providing education and making patients aware of the type of symptoms associated with pre-eclampsia and the need to return to the clinic or hospital as soon as these occur. Health care workers must be taught to screen for pre-eclampsia, to assess the severity appropriately, and to refer timeously. Information must be provided in respect of transport, in particular, the use of community transports services (e.g. neighbour's car, taxis). Institution of Continuous Professional Development for all health personnel at all levels of care, but especially at level 1 and 2 hospitals. An understanding of the pathophysiology of hypertensive disorders in pregnancy is essential to institute appropriate management. Protocols for management of hypertension and its complications should be formulated at a national level, modified for regional use and provided to all health facilities. An audit should be instituted to monitor their use in clinics and hospitals.
Clinical protocols must include the need for a complete assessment of the patient and management in specific situations, viz.: A clear system of referral patterns must be instituted and due attention given to cross-border transfers and co-operation between hospitals. Criteria for referral must also be established as well as their priority as emergencies. The creation of a post for a Regional Reproductive Health Care Advisor/Expert to provide continuous professional development, perform regular audits of protocols, develop systems of management of pre-eclampsia/eclampsia and update protocols, and carry out appropriate staff training. The importance of adequate monitoring of blood pressure, fluid balance and renal, hepatic, haematological and coagulation parameters must be made to all health care workers. It is mandatory to monitor fluid balance appropriately and be aware of pulmonary oedema.
Most of the deaths had avoidable factors and missed opportunities and we can only decrease deaths from pre-eclampsia once we have established a cause. In the mean time, we must recognise problems, make decisions, and institute timeous delivery. Delivery remains the only cure.
Discussion
Conclusions