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 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 2005-2008 2008-2010 2011-2013 2014-2016 2017-2019 2020-2022 Trend in embolism related iMMR Data regarding the site of delivery was available for 97 out of 116 files (83.6%) as shown in Table 3. The majority of deaths occurred in district hospitals (38, 39.2%) and regional hospitals (35, 36.1%). The highest institutional embolism related iMMR was observed in tertiary and national hospitals, with a rate of 5.1 per 100,000 live births, followed closely by regional hospitals at 4.3 per 100,000 live births. Notably, only 62 (53.4%) women underwent post-mortem examinations, suggesting that the rest of the diagnosis were established through clinical assessment and radiological investigations while the women were still alive. Table 3: Place of death and related iMMR N=97 CHC District Hospital Regional Hospitals Tertiary and National hospitals Embolism 4 (4.1%) 38 (39.2%) 35 (36.1%) 20 (20.6%) Pulmonary 4 (4.1%) 35 (36.1%) 27 (27.8%) 17 (17.5%) Amniotic fluid 0 (0.0) 3 (3.1%) 8 (8.2%) 3 (3.1%) Embolism iMMR 75 3.0 4.3 5.1 A total of 72 hard copies of clinical files out of the 116 women who died with a diagnosis of embolism were available for review. This comprised 61 files (59.8%) from the 102 and 11 (78.6%)cases out of the 14 women who died with a diagnosis of pulmonary and amniotic fluid embolism respectively. Among the women who died from pulmonary embolism, 35 (57.4%) out of the 61 assessed files had identifiable risk factors, with obesity being the most prevalent. This risk factor was present in 17 (27.9%) of the women who died, followed by hypertensive disorders of pregnancy, found in 11 (18.0%) women. In contrast, the majority (7 out of 11, or 63.6%) of women who died from AFE had no identifiable risk factor. Among the four women (36.4%) who presented with risk factors, obesity was the most prevalent, occurring in two cases (50.0%), followed by hypertensive disorders of pregnancy and diabetes, each at 25.0% (see Table 4). Table 4: Risk factors Pulmonary embolism (n=61) Amniotic fluid embolism (n=11) Obesity 17 (27.9%) 2 (18.2) Diabetes 4 (4.1%) 1 (9.1) Hypertensive disorders of pregnancy 11 (18.0%) 1 (9.1) Epilepsy 2 (3.3%) 0 (0.0) None 26 (42.6%) 7 (63.6%) Additionally, the hard copies of clinical files were also assessed for the most common presenting symptoms. Among the women who died from pulmonary embolism, the most frequently reported symptom was shortness of breath, occurring in 59 out of 61 cases (96.7%). In contrast, acute collapse was the most common presenting symptom amongst those who died from amniotic fluid embolism, reported in three out of eleven cases (27.3%). Only three women (4.1%) out of the total 72 reviewed files tested positive for COVID-19, all of whom were in the pulmonary embolism group. The incidence of pulmonary embolism increased with age, while the incidence of amniotic fluid embolism remained consistent across age groups (Figure 2). Figure 2: Age related trend in embolism related iMMR 0.0 2.0 4.0 6.0 8.0 10.0 12.0 10.-14 15-19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 Outside 10-44 range & Unk iMMR/100000 livebirths Age range iMMR for embolismsubcategory per age range -2020-2022 triennium -Pulmonaryembolism -Amniotic fluid embolism Avoidable factors were identified in the 102 cases . These factors included patient-related issues in 38 cases (32.8%), administrative in 37 cases (31.9%), and resuscitation-related problems in 43 cases (37.1%). The most common patient- related avoidable factors were late booking and delays in seeking help (21 out of 38 cases, 55.3%). Administrative related avoidable factors included delay in transferring patient from lower to higher levels of care and a lack of ICU beds (23 out of 37 cases,62.2%). Incorrect diagnosis and inadequate resuscitation were noted in 26(60.5%) out of the 43-resuscitation related avoidable factors. DISCUSSION Embolism is a leading cause of maternal mortality in high-income countries. 1-3 However, despite the rising prevalence of lifestyle-related risk factors for embolism, such as obesity, in low- and middle-income countries, the incidence of maternal deaths due to embolism in these regions, particularly in Africa, is under reported and poorly understood. The aim of this study was to assess maternal deaths due to embolism, with a specific focus on the profile of the women who died and identifying associated risk and avoidable factors. The number of embolism- related maternal deaths was higher during the 2020-2022 triennium compared to previous trienniums. Two possible explanations for this trend are: (1) improved diagnosis and the utilization of postmortem examinations, as indicated by a reduction in the number of maternal deaths classified as acute collapse of unknown cause during the 2020-2022 triennium compared to prior periods 11-15 , and (2) a possible increase in lifestyle-related risk factors, such as obesity, among pregnant women. In this study, the were more cases of pulmonary embolism related maternal deaths compared to amniotic fluid embolism. The above does not come as a surprise as amniotic fluid embolism is relatively rare compared to pulmonary embolism. Most of the women who died were relatively young (25 to 35 years) and had attended antenatal clinics. Of these, 45.1% were HIV-negative while 42.2% delivered via caesarean section. Overall, 57.4% of the study cohort had risk factors which included maternal obesity, diabetes, and hypertensive disorders of pregnancy. The risk factors African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | 16