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PowerPoint Discussion of Epidemiology of Acute Obstetric Emergencies
The incidence of acute medical and surgical emergencies in pregnancy and postpartum has increased during the past decade, and is expected to continue to increase in the future. This increase has resulted from the change in demographics of women who are pregnant or considering pregnancy ( Table 1-1 ), as well as the change in obstetric practice ( Table 1-2 ). Pregnancies in women 40 years and older (about 3%) are much more common than they were 10 years ago. Indeed, seeing women who are pregnant at age 50 or more is not an infrequent occurrence. This is related to the fact that more women are delaying getting pregnant to a later age (personal choice) or starting a new family (change in paternity). The availability of assisted reproductive technologies also has had an effect. With advanced maternal age there are increased rates of chronic hypertension, obesity, type 2 diabetes mellitus, preeclampsia, placenta previa, and abruptio placentae. In addition, these women are more likely to have multifetal gestation because of the need for assisted reproduction, and more likely to require cesarean delivery. The frequency of multifetal gestation among all pregnancies in the United States is 3.5%.
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The percentage of pregnant women who are obese or morbidly obese (20% to 30%) has also increased during the past decade. Obesity is associated with increased incidence of hypertensive disorders of pregnancy, type 2 diabetes mellitus and gestational diabetes, cesarean section, cardiopulmonary complications, anesthetic challenges, and wound infections/sepsis. The percentage of women who are pregnant for the first time is also increasing; these women are at increased risk for all types of hypertensive disorders, and are more likely to have elective induction of labor as well as emergency cesarean section.
A major contributor to medical and surgical emergencies is the increasing number of pregnant women with preexisting serious medical disorders (see Table 1-1 ). Because of improvements in medical and surgical care and advances in medical technology, pregnancy in women with severe cardiopulmonary disease and end-stage renal disease is more frequent than it was a decade ago.
The recent changes in obstetric practice have also led to an increased incidence of medical and surgical emergencies. The increased rates of elective cesarean section (primary on maternal request) and repeat cesarean sections have led to increased number of pregnant women with three or more cesarean sections. In addition, the presence of previous cesarean section increases the risks of placenta previa, abruptio placentae, and placenta accreta and percreta. These latter complications are more likely to result in massive blood loss, disseminated intravascular coagulopathy, cesarean hysterectomy, need for ventilatory support, and admission to an intensive care unit (ICU).
Multifetal gestation is associated with increased rates of placental abnormalities, preeclampsia, and preterm labor. In addition, uterine overdistention increases the risks of preterm rupture of membranes, abruptio placentae, and uterine atony. These women require prolonged periods of bed rest, which increases their risk for thromboembolism. Women with multifetal gestation with preterm labor requiring tocolytics and steroids for fetal lung maturity are also at increased risk for pulmonary edema and cardiomyopathy. Moreover, patients with multifetal gestation are more likely to require invasive diagnostic and therapeutic procedures such as cervical cerclage, serial amnioreduction, or fetoplacental surgery, procedures associated with an increased rate of obstetric emergencies.
In view of the above changes in maternal demographics and obstetric practice, it is prudent that all health professionals and obstetric units providing care for such patients be prepared to manage the expected increase in the number and percentage of medical and surgical emergencies in their obstetric population. Some of the steps that need to be taken to ensure patient safety and improve pregnancy outcome are listed in Table 1-3 .
