For Maternal-Fetal Medicine Specialists, All Eyes on Reducing Maternal Mortality and Morbidity

Each year in the United States, between 600 and 800 women die from pregnancy or childbirth-related complications. In addition to these heartbreaking maternal deaths, over 50,000 women experience severe morbidity, which can have myriad long-term consequences for a woman and her family.

At this year’s Society for Maternal Fetal Medicine (SMFM) Annual Pregnancy Meeting in Dallas, Texas, our attention was yet again on how we can strengthen our efforts to reduce maternal mortality and morbidity — and how we can better identify risk in our patients and measure the impact of our efforts.

Since 2012, Dr. Mary D’Alton has led a course entitled “Putting the ‘M’ back into Maternal Fetal Medicine,” which, in its first iteration, brought together leaders from the society to identify how improvements in MFM research, education, and clinical care could reduce maternal deaths. The priorities identified in this meeting have served as a roadmap for the last 6 years of work, and a “report card” will be published soon.

It was an honor to be asked to co-direct this year’s “Putting the ‘M’ back into Maternal Fetal Medicine” session with Dr. Michael Foley, and we quickly determined that our focus should be on hemorrhage. Obstetric hemorrhage remains a leading cause of preventable maternal mortality globally, but also nationally and locally. The course provided a broad overview of the problem and then short, focused interactive talks, updating members on practical considerations and recent evidence-based clinical management updates. Systems issues were discussed and the need for MFMs to take an active leadership role in local, regional and statewide programs to help drive improvement in outcomes was highlighted.

Multidisciplinary management and collaboration are essential to reducing maternal mortality rates. Our meeting included packed courses on both “Obstetric Critical Care Hands-On Simulation” and “The Pregnant Cardiac Patient-at highest risk of indirect maternal death: How to manage before, during and after pregnancy?” In the critical care course, we worked collaboratively with small groups of residents, fellows and experienced MFMs to manage simulated eclampsia, sepsis and maternal cardiac arrest.

Across the hall, an all-day sold out session for over 200 participants focused on another leading cause of severe maternal morbidity and mortality — maternal cardiac disease in pregnancy. Short, practical talks from multidisciplinary stakeholders including lead cardiologists in the field, anesthesiologists, intensivists, and MFMs provided a unique opportunity for all involved. While these two courses were designed quite differently, the energy, excitement and active learning occurring in each room was palpable. Imagine the impact as clinician participants return home and use these skills to care for patients, but even more importantly, to spread this learning by teaching others.

Scientific forums later in the week allowed participants to focus and share experiences with colleagues and trainees on Placenta Accreta (a leading cause of obstetric hemorrhage), Critical Care Obstetrics, Simulation and Obstetric Quality/Safety.

Research highlights included oral plenary sessions addressing two of the 3 leading causes of severe maternal morbidity and mortality — obstetric hemorrhage and hypertension. The TRAAP trial by Sentilhes et al. received the Bruce A. Work Award for Best Research by a Practicing or Training Maternal-Fetal Medicine Physician Outside of the US, presented a multicenter double-blind randomized controlled trial on the use of tranexamic acid for prevention of postpartum hemorrhage after vaginal delivery. Findings included the incidence of PPH (6.6% vs 8.8%, p=0.01), clinically-significant PPH according to caregivers (7.8% vs 10.4%, p=0.004) and need for additional uterotonics (7.3% vs 9.7%, p=0.003) were all reduced in the TXA group, without an increase in significant adverse events.

Data from the Illinois Perinatal Quality Collaborative (ILPQC) was presented by Dr. Ann Borders and received the Norman F. Gant Award for Best Research in Maternal Medicine. Through statewide quality improvement efforts, the percentage of new onset severe hypertension cases treated within 60 minutes increased from 41.5% to 78.9%, the percentage of cases receiving preeclampsia education at discharge increased from 14% to 65% and scheduling of follow up appointments within 10 days of discharge increased from 53% to 75%. In addition to improvement in these process metrics, the group reported decreased severe maternal morbidity in this vulnerable population of patients.

Multiple other abstracts, both oral concurrent and poster presentations, included work related to leading causes of maternal morbidity and mortality and obstetric management with potentially important implications for driving clinical standardization to reduce these risks. Research presented from NewYork-Presbyterian/Columbia University Irving Medical Center identified risk factors for postpartum readmission for VTE, which is another leading preventable cause of maternal mortality. The research indicated that risk of readmission was highest within the first 10 postpartum days and that a history of thrombophilias and advanced maternal age, along with a cesarean delivery, hemorrhage, or infection, increased readmission risk.

There is still much work to be done as women continue to experience preventable complications from pregnancy and childbirth. In less than two weeks, many SMFM members will reconvene at the New York Summit for Maternal Mortality — all of us with a bit more knowledge about the role of the MFM and the new research that will inform practice. Of course, we will continue to drive improvement in the care of our patients so that they can enjoy and fulfill their role as mothers.

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