AFJOG

ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | Increase in Embolism Related Maternal Deaths During the 2020-2022 Triennial Period in South Africa: A cause for concern ABSTRACT Background: Embolism is increasingly becoming recognized as an important cause of maternal mortality worldwide and the leading cause of maternal deaths in high-income countries (HICs) such as the United States and the United Kingdom. Despite the rising prevalence of embolism- related risk factors among pregnant women in Africa, there is a scarcity of data on embolism related maternal deaths from this region. Aim: To describe the profile of women who succumbed to embolism during the 2020-2022 triennium, along with associated risk and avoidable factors. Methods: Data from the Maternal Morbidity and Mortality Audit System (MaMMAS) database, together with hard copies of clinical records of women who died during the study period, were extracted and analysed using descriptive statistics. Additionally, Saving Mothers reports from 1999 to 2019 were reviewed to assess trends. Permission to publish the study was granted to the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) by the National Department of Health (NDOH). Results: During the study period, there were 3,019,165 deliveries and 3,803 maternal deaths, of which 116 (3.1%) were attributed to embolism, 102 (87.9%) and 14 (12.1%) of which were due to pulmonary and amniotic fluid embolism respectively. The majority of the women who died due to pulmonary embolism were aged between 25 and 39 years (81, 69.8%) and had attended antenatal clinics (88, 75.9%). Only 43 (42.2%) delivered via caesarean section. Among the women with risk factors, the identified risk factors included obesity, hypertensive disorders of pregnancy, and caesarean section delivery. Patient-related, administrative, and resuscitation-related issues were identified in 38 (32.8%), 37 (31.9%), and 43 (37.1%) of the maternal deaths, respectively. Addressing these factors is critical for reducing maternal deaths related to embolism in South Africa. Conclusion: Maternal deaths from embolism increased during the 2020 to 2022 period compared to the previous years. This trend underscores the need for nationwide risk assessment strategies, including risk-based thromboprophylaxis. Keywords: Maternal mortality, Pregnancy, Embolism, South Africa INTRODUCTION Embolism is an important cause of maternal mortality worldwide and ranks as a leading cause of maternal deaths in high-income countries (HICs) such as the United States and the United Kingdom. 1-3 The leading causes of embolism-related maternal fatalities are venous pulmonary embolism (PE) and amniotic fluid embolism (AFE), with AFE notably associated with high rates of resuscitation failure. 1 Additionally, the incidence of embolism is also observed in developing countries, where an increase in venous Thromboembolism(VTE) cases is linked to changing demographics, lifestyle changes, and increase prevalence of risk factors such as diabetes, HIV, obesity and other comorbidities. 4-5 Pregnant women are at increased risk of VTE which include deep vein thrombosis (DVT) and PE due to factors known as Virchow's triad: hypercoagulability, venous stasis, and vascular injury. 3,6 Pregnancy is a hypercoagulable state that is characterized by increased levels of clotting factors (Factors I, VII, VIII, IX, X, XI, XII, and von Willebrand Factor). 6-8 This state helps protect the mother and foetus from uncontrolled bleeding during labour and delivery. Additionally, pregnancy is associated with a marked decrease in circulating anticoagulants, notably a 60% reduction in Protein S and acquired Protein C resistance, together with reduced fibrinolysis activity due to elevated levels of Plasminogen Activator Inhibitor I and II. 7.8 The risk of VTE is further increased due to venous stasis resulting from compression of the inferior vena cava and pelvic veins by the gravid uterus, as well as endothelial injury that occurs during labour and delivery. Other VTE related risk factors include advanced maternal age, comorbidities, prolonged hospitalizations, and surgical procedures such as caesarean sections. While the pathophysiolocal mechanism is not clear in some of the risk factors, advanced maternal age, multiparity, induced labour, abdominal trauma, and caesarean delivery are associated with an increased risk of amniotic fluid embolism. 6-9 The 2020-2022 UK Confidential Enquiry into Maternal Deaths identified healthcare providers-related avoidable factors as the main contributing factors amongst the women who died of embolism, in particular, challenges with risk assessment and resuscitation skills. 3 There is limited data on embolism related maternal deaths in Africa including South Africa. The aim of this study was to assess the profile, risk factors, and avoidable factors contributing to embolism related maternal deaths in South Africa during the triennial period 2020 to 2022, aiming to use the information to recommend targeted interventions. MATERIALS AND METHODS The data for this study is derived from the National Confidential Enquiry into Maternal Deaths (NCEMD) and a L Chauke 1 ; S N Cebekhulu 2 1 Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand and National Committee on Confidential Enquiry into Maternal Deaths (NCCEMD)-South Africa. 2 Department of Obstetrics and Gynaecology, Dr George Mukhari Academic Hospital-Sefako Makgatho Health Science University, Gauteng Department of Health, Gauteng, South Africa and National Committee on Confidential Enquiries into Maternal Deaths-South Africa. CORRESPONDENCE: L Chauke | Email: lawrence.chauke@wits.ac.za Increase in Embolism Related Maternal Deaths During the 2020-2022 Triennial Period in South Africa: A cause for concern African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | 14