Pregnancy in patients with Eisenmenger syndrome (ES) is associated with high maternal mortality rates of 30%‒50%, or even up to 65% in the case of a cesarean section (Yuan, 2016). Here, we report a case of term pregnancy complicated with ES and severe pulmonary artery hypertension (PAH), which was managed by a multidisciplinary team (MDT) and resulted in an uncomplicated delivery via elective cesarean section. The goal of this study is to emphasize the importance of multidisciplinary approach in the management of pregnancy with ES, which can profoundly improve maternal and infant outcomes.
Female ; Humans ; Pregnancy ; Cesarean Section ; Eisenmenger Complex/therapy* ; Hypertension, Pulmonary/therapy* ; Maternal Mortality ; Pregnancy Complications, Cardiovascular/therapy* ; Pregnancy Outcome

Introduction: Implementation of Basic Emergency Obstetric and Newborn Care (BEmONC) aims to curb maternal mortality. However, the Philippines failed to significantly reduce the maternal mortality rate (MMR) targeted in the Millennium Development Goals (MDGs). Currently, the country is still far from the targeted Sustainable Development Goals (SDGs). This review describes the historical development of BEmONC in the Philippines over the past 13 years and provides insights on its role in decreasing MMR. Methods: We searched online for journal articles, publications, reports, policies, and other issuances related to BEmONC and maternal health in the Philippines. We accessed updates and data via correspondence with the Department of Health (DOH). Statistics were compiled from public databases. The identified citations were screened, appraised, synthesized, and analyzed in a historical approach. Results: A direct result of the Emergency Obstetric Care Approach, BEmONC was developed to respond to the high MMR in the Philippines, in line with global efforts to improve maternal health. However, BEmONC functionality generally remained inadequate. Conclusions Although the provision of BEmONC services increased facility-based deliveries and skilled birth attendance during childbirth, this failed to decrease MMR and achieve targeted goals substantially. Further capacity-building is needed, especially in rural and resource-poor areas. Government issuances at the national and local levels should be aligned to complement each other. There should be a health systems approach that considers the building blocks of an efficient health care system and the social determinants that impact them.
Maternal Health Services ; Maternal Mortality

Background Background. Establishing and integrating Basic Emergency Obstetrics and Newborn Care (BEmONC)-capable facilities into the healthcare delivery system is one of the strategies employed by the Philippine government to address high maternal mortality. Objectives. This study aimed to determine the functionality of BEmONC-capable rural health units (RHUs) in Luzon, the largest island in the country. Methods. The study utilized a researcher-administered facility survey and facility observation using a checklist designed to measure BEmONC functionality. Facilities were selected through a two-stage sampling method. A BEmONC Score Card was used to determine the overall functionality of a facility based on three categories — institutional capacity, service capacity, and personnel capacity. The total scores from the three categories provided the overall functionality score.Results. Of the 245 BEmONC-provider RHUs included in the study, 85 (35%) were adequately functional. The mean functionality score for Luzon (60±25.27) corresponded to adequate functionality. The mean institutional and service capacities were consistently high across all regions on the island. Still, the personnel capacity did not reach the minimum average, pulling down the overall score and leading to low overall functionality. Conclusion. The BEmONC facilities continue to function despite being hampered by factors that can be easily remedied. The provision of BEmONC services remains relevant across all regions in Luzon as they fill in the gaps and serve the needs of mothers and pregnant women. This study should be replicated in the Visayas and Mindanao to obtain a complete representation of the BEmONC program.
Maternal Mortality

Introduction: There is insufficient local data on the maternal and fetal morbidity and mortality of cases seen initially at the primary health-care facility (PHCF) and subsequently referred to a tertiary hospital for acute management. This study aimed to determine the maternal and fetal outcomes of such patients using the World Health Organization maternal near miss, mortality, and neonatal mortality rates. Materials and Methods: A cross-sectional study was done that involved obstetric patients beyond 20-week gestation and in the immediate postpartum who were initially managed at the PHCF then referred to a tertiary hospital for management. Results: There were 485 deliveries (85.5%) with a primary cesarean section rate of 16.6%. One patient underwent exploratory laparotomy for uterine rupture with extraction of a stillborn baby and hysterectomy. Eighteen cases (3.2%) necessitated other forms of surgical interventions including hysterectomy (6), transverse compression suture (3) with bilateral uterine or hypogastric artery ligation, uterine repositioning (1), evacuation of vaginal hematoma (4), balloon pack insertion (2), postpartum curettage (1), and removal of retained suture needle (1). The maternal near-miss rate is 46.7/1000 live births (46.7%). There were three intensive care unit admissions and 5 cases required ventilatory support. The maternal mortality rate is 10.6 maternal deaths per 1000 live births (1.06%). Majority of the babies had good APGAR scores at birth. Twenty-two babies (4.5%) required intensive neonatal management. The neonatal mortality rate is 0.42% or 4.2/1000 live births. Conclusion Almost 40% of referred cases were primigravidas and have preexisting medical problems that should not have been seen at the primary care level but directed to secondary or tertiary center at the outset. It cannot be understated that education of the populace, more training, and monitoring the performance of base health facility workers should be done to prevent maternal and fetal catastrophes.
Maternal Mortality ; Fetus ; Morbidity

OBJECTIVES: To report our experiences in pregnant patients with pulmonary arterial hypertension (PAH) who were treated with targeted therapy. METHODS: From 2011 to 2017, women who decided to maintain pregnancies in our PAH clinic were included. Clinical data, management, and outcomes of the mothers and fetuses were reviewed. RESULTS: Nine women with PAH and 10 deliveries were reviewed. The median maternal age was 28 (26–32) years old. The functional status of each patient was New York Heart Association functional class II or III at first visit. Sildenafil was prescribed in advance in 9 cases of delivery. Multidiscipline team approach management and intensive care were performed during the peripartum period. There was no maternal or fetal mortality. Severe cardiac events occurred in 2 patients with Eisenmenger syndrome: cardiac arrest and uncontrolled arrhythmia. Non-cardiac events occurred in 3 cases: postpartum bleeding, urinary tract infection, and pneumonia. The median gestational period at delivery was about 34 (32–38) weeks. Three cases were emergent delivery because of unexpected preterm labor. Intrauterine growth restriction developed in 4 fetuses. CONCLUSIONS: Pregnancy could be maintained by the introduction of targeted therapy rather more safely than the previous era in the case of maintenance of pregnancy. Intensive care and a multidisciplinary team approach can possibly improve the outcomes of the pregnant women with PAH and their babies. However, pregnancy in patients with PAH is still strongly prohibited and it can be tried in expert center where there has sufficient multidisciplinary team approach in case of inevitability.
Arrhythmias, Cardiac ; Critical Care ; Eisenmenger Complex ; Female ; Fetal Mortality ; Fetus ; Heart ; Heart Arrest ; Hemorrhage ; Humans ; Hypertension ; Hypertension, Pulmonary ; Maternal Age ; Mothers ; Obstetric Labor, Premature ; Peripartum Period ; Pneumonia ; Postpartum Period ; Pregnancy ; Pregnant Women ; Sildenafil Citrate ; Urinary Tract Infections

Currently, the rate of cesarean sections being performed in Korea is approximately 40%, with Korea ranking 4th among the Organization for Economic Co-operation and Development countries with respect to cesarean deliveries. Breech presentation at term is an important indication for cesarean section among other factors, including medicolegal concerns and pregnancies in women of advanced maternal age. Term breech presentation is associated with a higher fetal mortality rate than that associated with a cephalic presentation. Therefore, in Korea, most of these women deliver by cesarean section to avoid the complications of vaginal breech delivery. However, cesarean section is itself associated with considerable obstetric morbidity and sometimes, mortality. External cephalic version (ECV) is a useful method to reduce the cesarean section rate in women with breech presentation and therefore to reduce the incidence of breech presentation at delivery. Studies have shown that routine use of ECV reduces the cesarean section rate by approximately two-thirds in term pregnancies with breech presentation. ECV is accepted as a safe, efficacious, and cost-effective method and is recommended by both the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists in all pregnancies with term breech presentation, if not contraindicated. In Korea, although most clinicians are aware of the option of ECV, their relative lack of experience in performing the procedure and fear of complications render them hesitant to perform ECV. This review is aimed at guiding obstetricians by describing the efficacy, safety concerns, and technical aspects of this procedure.
Breech Presentation ; Cardiotocography ; Cesarean Section ; Female ; Fetal Mortality ; Humans ; Incidence ; Korea ; Maternal Age ; Methods ; Mortality ; Pregnancy ; Version, Fetal

OBJECTIVES: The aim of this study is to demonstrate how an integrated information system of mother and toddler cohorts can be developed as a basis of the continuum of care approach that subsequently can be used as the basis of early detection of risk factors of maternal mortality. METHODS: This research was carried out qualitatively. The data was collected through three techniques: in-depth interviews, focus group discussion, and document studies at six public health centers located in four sub-districts of Surabaya, Indonesia. This research was conducted from 2016 to 2018. RESULTS: The data collected from this research has become a basis input data requirement analysis for an integrated mother and toddler cohort information system. The system accommodates all the variables in each period of pre-marriage, pregnancy, labor, infancy and toddlerhood. The system facilitates healthcare workers to retrieve data and information related to mother and toddler health status. CONCLUSIONS: The availability of various pieces of information enables the health status of mothers and toddlers to be monitored thoroughly throughout their long-life cycle. This continuum of care approach is beneficial in the early detection and management of risk factors of maternal mortality, such as pregnancy complications as well as childbirth and postpartum complications.
Cohort Studies ; Continuity of Patient Care ; Delivery of Health Care ; Focus Groups ; Humans ; Indonesia ; Information Systems ; Maternal Mortality ; Maternal-Child Health Services ; Mothers ; Parturition ; Postpartum Period ; Pregnancy ; Pregnancy Complications ; Public Health ; Risk Factors

OBJECTIVES: Since many Millennium Development Goals (MDGs) were not achieved, countries including Iran—despite achieving some of the MDGs—need regular planning to achieve the Sustainable Development Goals (SDGs) by 2030. This article examines maternal and child health indicators in the early years of the SDGs in Iran relative to several other countries.METHODS: This study was carried out through a secondary analysis of maternal and child health indicators in Iran. The results were compared with data from other countries divided into three groups: countries with upper-middle income levels, countries in the Eastern Mediterranean region, and the countries covered by the Outlook Document 1,404 (a regional classification). Then, the relationship between these indicators and the Human Development Index was investigated.RESULTS: Iran has attained better results than other countries with respect to maternal mortality, family planning, skilled birth attendance, under-5 deaths, incidence of hepatitis B, diphtheria-tetanus-pertussis vaccination coverage, and antenatal care. In contrast, Iran performed worse than other countries with respect to under-5 wasting, under-5 stunting, and care-seeking behavior for children.CONCLUSIONS: Overall, among the 11 indicators surveyed, Iran has attained better-than-average results and seems to be improving. We recommend that Iran continue interventions in the field of maternal and child health.
Child Health ; Child ; Conservation of Natural Resources ; Family Planning Services ; Growth Disorders ; Hepatitis B ; Human Development ; Humans ; Incidence ; Iran ; Maternal Health ; Maternal Mortality ; Mediterranean Region ; Parturition ; Vaccination

Background: Since 1976, Bicol Region had higher maternal mortality ratio (MMR) than the Philippine average and became the fourth region with the highest MMR in 2012. Looking at trends of maternal health outcomes and determining risk factors among mothers who died may guide interventions to reduce MMR. Objectives: To determine the changes in maternal mortality ratio (MMR) in the Bicol region from 2004 to 2017 and determine the sociodemographic profile of pregnant women who died from 2015 to 2018. Materials and Methods: A records review of Bicol?s Regional Field Health Services Information System from 2004 to 2017 and maternal death review reports from 2015 to 2018 was done. Changes in MMR was determined using Poisson regression. The sociodemographic characteristics and causes of maternal deaths were analyzed using frequencies and proportion. Results: From 2004 to 2017, MMR of 100.9 remained higher than the regional target of 31.6. Significant reductions in MMR were achieved in 2007 to 2008 and in 2011 to 2012 wherein MMR ranged between 75.3 to 89.3. However, by the end of 2012, maternal deaths again increased which reached 122.5 in 2017. From the maternal death reviews, it was observed that 29.5% of maternal deaths were aged 35 years and above and 7.5% were less than 20 years old. Mothers who had more than five pregnancies were 30.1% of total deaths. In terms of place of death, 15.7% died at home or in-transit to referral facilities. Hemorrhage or hypertension-related causes were the leading reasons for maternal deaths. Conclusion Significant reduction in MMR was not sustained after 2012 and higher deaths were reported in the succeeding years. Maternal deaths can be further reduced by using a systems approach, by promoting family planning, and by strengthening service delivery networks to effectively manage hemorrhage and hypertension-related emergencies.
Maternal Mortality ; Maternal Health

Pre-eclampsia (PE) is a pregnancy disorder that is characterised by severe hypertension and increased risks of foetal and maternal mortality. The aetiology of PE not completely understood; however, maternal nutrition and oxidative stress play important roles in the development of hypertension. The treatment options for PE are currently limited to anti-hypertensive drugs. Punicalagin, a polyphenol present in pomegranate juice, has a range of bioactive properties. The effects of supplementation with punicalagin on angiogenesis and oxidative stress in pregnant rats with induced hypertension were investigated. The pregnant rats were randomly divided into five experimental groups (n=12 per group). Hypertension was induced using an oral dose of NG-nitro-L-arginine methyl ester (L-NAME, 50 mg/kg/day) on days 14–19 of pregnancy. Punicalagin (25, 50 or 100 mg/kg) was given orally on days 14–21 of pregnancy. Punicalagin treatment at the tested doses significantly reduced diastolic, systolic, and mean arterial blood pressure in L-NAME treated rats from day 14. Punicalagin also restored angiogenic balance by increasing the expression of vascular endothelial growth factor and downregulating vascular endothelial growth factor receptor-1/fms-like tyrosine kinase-1. Punicalagin, significantly increased the placental nitric oxide levels as compared to PE group. The increased levels of oxidative stress in rats with PE were markedly decreased by treatment with punicalagin. Punicalagin at the tested doses markedly (p < 0.05) enhanced the placental antioxidant capacity in L-NAME-treated rats. The raised catalase activity observed following L-NAME induction was significantly (p < 0.05) and restored to normal activity levels in punicalagin treatment. Further, 100 mg dose of punicalagin exhibited higher protective effects as compared to lower doses of 25 and 50 mg. This study shows that supplementation with punicalagin decreased blood pressure and oxidative stress and restored angiogenic balance in pregnant rats with induced PE.
Animals ; Antihypertensive Agents ; Arterial Pressure ; Blood Pressure ; Catalase ; Female ; Hypertension ; Hypertension, Pregnancy-Induced* ; Maternal Mortality ; Models, Animal* ; NG-Nitroarginine Methyl Ester ; Nitric Oxide ; Oxidative Stress* ; Pre-Eclampsia ; Pregnancy ; Punicaceae ; Rats* ; Tyrosine ; Vascular Endothelial Growth Factor A