Maternal deaths due to spontaneous subarachnoid hemorrhage ALEX
BARNO,
M.D.
D. W. FREEMAN, Minneapolis,
M.D
Minnesota
Spontaneous subarachnoid hemorrhage due to ruptured berry aneurysm and arteriouenous malformation accounted for 4.4 per cent of all maternal deaths in the State of Minnesota,from 1950 to 1973. This catastrophic entity ranked eighth in frequency regarding all causes of death and third among the nonobstetric causes. An analysis of the 37 deaths among 1,763,824 live births is pesented. These 37 patients had delivered 96 infants and had 10 spontaneom abortions prior to current pregnancy. Thic suggests that of the hemorrhage. Five pregnancy per se has no app-Pciub~e effect upon th e occurrence of these died in association with labor and delivery, or during a 1 da! period-three during labor, one dun’ng vaginal delivery. and one only 1 hour postpartum. This is equivalent to 35 per week. On the other hand, 15 occurred during pregnancy (undelivered) (0.4 per week) and 17 during thejrst 3 months post partum (-1.4 pn week). The.ye data seem to indicate that labor and deliveq increase the risk of spontaneous suba.rachnoid hemomhage. The neurologic state of these 37 patients ulas bad from the very onset of the hemorrhage. Rapid irreversible coma occurred in 34 (76 per cmt). Oj these 34, 23 (74 per rent) were dead within the$r.st 24 hours and 32 (94 per cent) were dead zoithin the first 4 days following the onset qf the hemorrhage.
IT IS THE PURPOSE of this paper to analyze the maternal deaths due to spontaneous subarachnoid hemorrhage which occurred in the State of Minnesota for a 24 year period, 1950 CO 1973. These were deaths due to ruptured berry aneurysm and arteriovenous malformation. Isolated case reports, series, and composite series of cases occurring during pregnancy and the postpartum period have appeared in ~hc literature’-l3 but it is the opinion of the authors thal this accumulalion of a large series of 37 deaths with detailed study warrants reporting.
state to study the hospital record, the prenatal record. and interview the physicians and all other persons involved in the management of every maternal death. All deaths associated with pregnancy and the 3 month postpartum period are investigated. The data are then presented in protocol summary to the Minnesota Maternal Mortality Committee-23 members representing the entire state. Final decisions are then made as to the cause of death, criticism of handling of the case as to care being adequate, faulty and contributor) to death, or faulty and not contributory with regard to prenatal care, labor and delivery and postparwm care. Analysis is made of the autopsy, completion of the death certificate, the birth and/or death certificate of the infant, and final assessment is made as to the prevenlability of death and responsibility for the death. The protocols of the 37 deaths due to spontaneous subarachnoid hemorrhage were carefully analyzed.
Materials and methods The data were obtained from the Minnesota Maternal Mortality Study which has been a continuous one since 1950. Previous publications 14, l5 have elucidaled the mechanics of the study. Suffice it to say that Board-certified obstetricians travel throughout the
Rssults From the Minnesota
Maternal
Morfality
Stud!.
The 37 deaths births resulted in an incidence births, or 1.5 per year. During (1950 to 1973) there were a d(:aths-483 obstetric (where Incidence.
Presented at the Forty-third Anwal Meeting of thr Central Association of Obstetricians and Gynecologists, Colorado Spings, Colorado, September 26-28, 1975. Reprint reqwrts: Dr. Alex Barm, Minneapolis, Minnesota 555316.
5000 W. 39th St., 384
among 1,763,824 live of one per 47,671 live this 24 year period total of 843 maternal pregnancy played a
Maternal deaths due to subarachnoid hemorrhage
Volume Number
125 3
Table
I. Maternal
deaths, Minnesota,
Came
1
Obstetric hemorrhage Obstetric infection* Trauma Toxemia Heart disease Malignant tumors Amniotic fluid embolism Spontaneous subarachnoid hemorrhage Not determinable Chorionepithelioma Poliomyelitis Anesthesia Peritoniti:i Air embolism Pneumonia Infectious hepatitis Leukemia Transfusion deaths Diabetes mellitus Glomerulonephritis Dehydration and electrolyte imbalance Coronary occlusion Bronchial asthma Ruptured aortic aneurysm Others Total *Includes
pulmonary
1950-1973
NO.
1
Per cent
119 98 95 68 49 45 39 37
14.1 11.6 11.3 8.1 5.8 5.3 4.6 4.4
36 26 25 20 19 16 11 8 8 7 6 5 5
4.3 3.1 3.0 2.4 2.3 1.9 1.3 0.9 0.9 0.8 0.7 0.6 0.6
5 5 5 86 843
0.6 0.6 0.6
10.2 100.0
embolism.41
causitive role) and 360 nonobstetric. Table I shows a breakdown of these 843 maternal deaths as to primary causes (both obstetric and nonobstetric). It is seen that this catastrophic entity ranked eighth in frequency regarding all causes of death and third among the nonobstetric causes. All of these patients were normotensive before the tragic episode of spontaneous subarachnoid hemorrhage except for one. She was a 42-year-old para 3 who had hypertensive vascular disease and died during labor at 31 weeks’ gestation. Autopsy showed a ruptured berry aneurysm. There was no history of trauma in any of these 37 patients and none had had a previous subarachnoid hemorrhage. Table II shows that, of all the maternal deaths due LO cerebral hemorrhage for the 24 year period under consideration, spontaneous subarachnoid hemorrhage due to ruptured berry aneurysm and arteriovenous malformation accounted for 51 per cent. Toxemias accounted for 35 per cent and the remainder as enumerated. Source of reporting. The mechanism via which these deaths were discovered is shown in Table III. Had reliance been placed on death certificate information alone, one half of these cases would have been missed, since pregnancy or the postpartum state was not recorded on the death certificate in 18. Eight were
385
Table II. Maternal deaths due to cerebral hemorrhage, Minnesota, 1950- 1973 Came
NO.
Per cent
Spontaneous subarachnoid (Berry aneurysm and A-V malformation) Toxemia Eclampsia and pre-eclampsia (16) Hypertensive vascular disease with functional increment (5) Hypertensive vascular disease without functional increment (4) Choriocarcinoma
37
51
25
35
Brain tumor (astrocytoma) Thrombocytopenic purpura Myelomonocytic leukemia Hypersplenism Autoimmune disease Total
Table III. Source of reporting, spontaneous subarachnoid hemorrhage, Minnesota, 1950- 1973 Source Death
certificate
No.
Per cmt
19
51
18
49
(complete and correct) Other sources* X-match (8) Hospital record room (4) Other physicians (3) Field investigator (2) Original physician. (1) Total *Pregnancy certificate.
or postpartum
37 state not
mentioned
100 on death
discovered by the cross-match (x-match) technique. The Vital Statistics Section of the Minnesota State Department of Health pulls all death certificates of women aged 15 through 45 and for each of these, searched for a birth or fetal death certificate. The other 10 were discovered as enumerated in Table III. Of these 10, eight would have been picked up by the x-match technique but two would have been missed since they died undelivered. Regarding all the maternal deaths (843) during the 24 year period under consideration ( 1950 to 1973), one third would have been missed since pregnancy or the postpartum state was not recorded (Table IV). Thus, reports in the literature regarding the incidence of spontaneous subarachnoid hemorrhage as a cause of maternal death, based on death certificate information, are inaccurate. “Committee efforts” warrants elucidation. Before the Minnesota Maternal Mortality Study was begun, all physicians and hospitals in the state were notified-the physicians via communication in Min-
386
Barno and Freeman
Table
IV.
Minnesora,
Source of reporting, 1950- 1973
maternal
cleaths,
s o,ltTI’ Death certihcate Commirtec efforts
*Not included as a marernal death in viral statistics. V. Age, spontaneous subarachnoid hemorrhage, Minnesota. 19% 1978
Table
,4ge
Table
VI.
spontaneous 1950-1973
Parity (excluding suharachnoid
r~cotn M~ciicit~,
so.
Per WNf
present pregnancy). hemorrhage, Minnesota.
the stale medical journal, and via ihe from the Stale Medical Association and the hospitals via letters. As the study unfolded and has been publicized in medical circles, information regarding maternal deaths is being presented lo the committee by the physicians involved, other interested physicians, nurses, social workers, and medical record-room personnel. The field investigators have discovered cases thal would have been missed b? inquiring a~ hospitals regarding other maternal deaths thal might have occurred. The x-match technique has already been described. Information is also obLained b) auditing newspaper reports. The authors are of the opinion that in spite of all of this, some maternal deaths are still being missed, especially of those who die undelivered. Autopsies. Documentaion of’ these cases was excel121rdical
Nrwskttu
lent. ‘I‘wcnty-nine (78 per cent) had autopsies, ittclutiittg the head. In the other eight (29 per cent) rhc diagnosis was ~nacle on lhc basis of histor), c,linical findings. bloody spinal tap, elevated spinal fluid pressure, and/or artrriogt-aphv. Kegarding the 2!) autopsies, a ruptured berrv aneurvsm was ti~utltl in 13, artertovenous malfortn;~tion in foyer. and in ten hentot rhage was so rttassivts aiitt slt~uc~turos so descrovt~tl (vessels and surrounding brain tissue) that identifica(iott of the aneurysm US impossible. Of the fi)ttt arteriovcnous ttt;tlfortnatiotrs, these occur-t-& a( 7 davs post parntm. ZSweeks post parcum. 8 weeks’ gesiatiott (ttntlrliverrd). atltl 12 \+ccks’ gr‘station (tlntlelivctt,c,tl). Age and parity. As seen in .I‘ahle L’. one thircl c)f these patients wcrc in 1he 50 to 3.4 year age group. 1, ilh the secot~ti largest number (22 per c‘cn~) ilt the 2.5 to Z!j calegorv. Parity (esc litding present pregtlallcv) is sutnmarized ii, Tat+ VI. ~I‘hesc 37 pti~lllY hat1 deliverc~d 96 irtf’&lls and had had IO spontaneous aborciotts print LO current prcgnant~y. ~I‘his .ruggests that pt-egnancv per SC has IIO appreciable effect upott ht. occurrent c of the cnrit\ Time of occurrence. fable VII presrnrs a11 analysis regarding the time of’ occurrence of 01~ subarachnoid hemorrhage. Almost one half of these occurre(l during lhc posIparLum stale :III~ 11 per- cc~it in lhc undelivered. Of the I5 utndelivered. IO (Iwo thirds) occ urrtyl in Lhe last trimc.ster. .L\ most significattt fittdiiig was that in four paticnls the episode occurred during labor OI vaginal clelivt~r\.. Hunr and associales’” in a recrrll publication. stared. ” 1‘0 our knowledge. onlv ant’ hemorrhage from a tlocumenLed ancur~sm has been reported (luring labor or \.aginal tieli\:er\:.‘~ l;ivc patients in this series died in association \vith lahor ;IIKI deliver>-. or during a I day periotl--thrcyi during labor, one during vaginal deliver\. and OllV only 1 hOll1 poslpartutn. ‘l‘his is equivalent IO 3.5 [ICI’ keel\. 011 cht, other hand, 15 occttrrrtl during pregnancy (undelivered) (0.4 per week) a~td 17 during rhc :< ntonths postpartum ( 1.4 per \veck). .I‘hesr: data seem IO itttlical(’ that labor and deliver-\ increase the risk of spontant*otts subarachnoid hemorrhage. Duration
of
life
after
spontaneous
subarachnoid
[‘hat this is a catastrophic entity is illust.raled b\, the fact that 68 per cent of these patieltrs died withit? Ihe first 24 hours of Ihe occurrence of (ht. hemorrhage.
helllorrhagc,
86 per
WILL died
within
4 days.
and
93 per.
wilhitt I1 clays (Table VIII). Most of the patietttx in [his herirs died brfi1t.c surgel-1 c~ould I)c c onsitlered. Only IWO wc‘rc’ subjected IO surger!. ‘I‘he first \V;LS ‘I Z-year-old para Y who had spontaneous subarachnoid hetnorrhagc AI I6 \\ecks’ gestation. .4ngiograph\ i L’ cent
d2lks
Iillrr
shc~~\ctl
2 bcl-ry
alleUwsrn
extending
off
the
Volume Number
125 3
internal carotid artery in the region of the anterior choroid artery and posterior communicating artery. Craniotomy under hypothermia anesthesia was performed 2 days later-the carotid was clipped proximal and distal to the aneurysm and a clip was placed on the neck of the aneurysm. She died 2 days postoperatively. The second patient was a 41-year-old para 8 who developed spontaneous subarachnoid hemorrhage during labor at term. She was delivered by low forceps extraction. Even though the patient was in a coma, carotid angiography was done and this showed an aneurysm of the middle cerebral artery. The neurosurgeons elected to perform craniotomy 1 week following the hemorrhage even though the patient had remained in coma but she died a few hours postoperatively. IL is not the intention of the authors to dwell on the neurosurgical treatment. This has been adequately covered by Pools and others. The basic principles are supportive therapy then, as the condition of the patient warrants, angiography for diagnosis and then surgery as indicated. Neurologic state. The neurologic state of these 37 patients was bad from the very onset of the spontaneous subarachnoid hemorrhage and the prognosis was grave, as indicaled in Table IX. Rapid irreversible coma occurred in 34 of these patienls (including Lhe two who were found dead after having complained of severe headache) (76 per cent). Of these 34 patients, 25 (74 per cent) were dead within the first 24 hours and 32 (94 per cent) were dead within the first 4 days following the onset of the hemorrhage. The condition of the patients was so grave LhaL diagnostic arteriography could no1 be done and certainly they were in no condition for surgical treatment. The neurologic state of Lhe other three patients is self-explanatory (Table IX). The mosL common symptom presenled by the patients was sudden excruciating headache. This occurred in 26 of the 37 patients (70 per cent). 1~ is not the intention of Ihe authors to try to statistically analyze the various other neurologic findings present in addition to the coma. Twemy-four of the 37 patients had spinal fluid taps. Twenty-two of lhese were grossly bloody and two were xanthochromic. In 14, the cerebrospinal fluid pressure was measured-markedly elevated in 13 and normal in one. Method of delivery. Twenty (55 per cent) were delivered via the vaginal rouLe (Table X). Two patients were delivered by cesarean section. One was a 21year-old primigravida with spontaneous subarachnoid hemorrhage occurring during labor at 40 weeks’
Maternal deaths due to subarachnoid
hemorrhage
387
Table VII. Time of occurrence, spontaneous subarachnoid hemorrhage, Minnesota, 1950-1973 Timp
Postpartum 1 hour (1)
1
No.
1
Per cent
18
48.6
15
40.5
4 days (1) 7-10 days (4) 12 days (1) 3-4 wk. (5)
5-9 wk. (5) 12 wk. (1) Undelivered (no labor) First trimester (2) Second trimester (3) Third trimester ( 10) During labor During vaginal delivery Total
Table VIII. subarachnoid
3
8.1
1 37
2.7 99.9
Duration of life after spontaneous hemorrhage, Minnesota, 1950- 1973 Time
NO.
Per cent
First 24 hours Immediate (DOA) (1) I5 minutes (2) 2-4.5 hr. (6) 6-9 hr. (5) lo-12 hr. (5) 14-17 hr. (3) 21-24 hr. (3)
25
67.6
3 4 3
8.1 10.8 8.1 2.7 2.7
44-55 hr. 3-4 days
6-l 1 days 16 days 42 days Total
1 1 37
100.0
gestation with the cervix 5 cm. dilated. Low-segment cesarean section was done under local anesthesia for fetal salvage since the patient was in coma and considered to be moribund. A normal infant weighing 6 pounds, 8 ounces was obtained. Her total labor had been 11 hours. The other patienL was a 3%year-old para 3 who was delivered at 37 weeks’ gestation by repeat classical cesarean section. Spontaneous subarachnoid hemorrhage occurred at 29 days postpartum. Of the 15 patients who died undelivered (40 per cent), three had postmortem cesarean sections with no surviving infants. Outcome of infant. The fetal mortality rate is shown in Table XI. IL is high, as we would expect (42 per cent), but it is amazing that 58 per cent of these infants survived. Other data. All of these patients were Caucasian excepl for two Negroes. The 1970 population of Minnesota was 3,805,069, with 98 per cent Caucasian
388
Barno
June
and Freeman Am. J.
Table IX. Neurologic state correlated with time of occurrence subarachnoid hemorrhage, Minnesota, 1950- 1973 the ,\‘o. R’ot feeling I
13
22 33
Found
9 I .i 19 30
coma (six putze,,ts): During delivery at 40 wk. 33 wk.
3 wk. pp During labor at 31 wk. 7 days pp. 9 days pp.
Sudden severe headache and found I8 34 wk. ?I
of life after spontaneous
statr
restless, then ,found it1 irrrurrsihle coma (four patients): 12 wk. pp. Pt. called husband at I 1 A.M. about not feeling well and being restless. He came home I% hr. later and found her in coma 9 \vk. pp. Didn’t feel well and restless. Short time latrrhusband found her with gasping respirations and in coma 7 wk. pp. At 4 A.M. became restless. Few minutes later husband heard a fall and found her in coma on the floor During labor 41 5:30 P.M. patient becatne restless and confused. at 40 wk. Cervix S-cm. dilated. .4t 6:25 P.M. developed convulsions and coma
iu meverszble 4 ti
Nru7obgi~
Tk ~4,
and duration
1. 1976
Obstet. Gynecol.
8 wk. pp.
Cy~lo anesthesia for outlet forceps. Never- regained consciousness Pt. awakened in A.M. and asked for glass of milk. 0n his return with the milk, husband found her in coma Husband found her comatose in basement at 5: I.5 P.M. Pt. in earlv labor. At routine check nurse found her with cyanosis and in coma Found in coIna in bathroom by her childrrll Collapsed while walking downstairs. Found in coma by husband
&ad (two patier&): Severe sudden headache and went to bed at 8 P.M. Husband found her dead at 3: 15 A.M. next morning Sudden severe headache. Husband went to drug store fi~r analgesic-. On his return he fnund her dead on the floor
and 2 per cenL non-Caucasian-Negro, 0.9 per cent; Indian, 0.6 per cenL, and others, 0.5 per cent. Carotid angiograms were performed on four patients and an aneurysm was demonslrable in each. Associated disease was present in nine of these 37 patienLs--obesity in four (190, 212, 235, and 246 pounds), polycysLic kidney disease, alcoholism with multiple sclerosis, congenital Lorticollis, peLi1 mal epilepsy, and M&&e’s disease. As previously noted, all of Lhese patients were normotensive before the episode except one. After the episode of spontaneous subarachnoid hemorrhage Lhe blood pressure was elevaled in 19, normal in nine, at shock levels in three, and no1 recorded in six. The increase in blood pressure is due Lo the increased intracranial pressure. The case protocols were perused as to whether the administration of oxyLocic drugs might have contributed to the rise in blood pressure. This was so in only one insLance. This patient received 1 c.c. of methylergonovine maleate (Methergine. Sandoz), 0.2 mg. intravenously, afLer the delivery of the placenta because of uLerine atony (400 c.c. estimaLed blood loss). She was normotensive before spontaneous
7 hr. I5 min.
delivery. One half hour afLer Lhe meLhylergonovine maleate, her blood pressure rose Lo 160/W. 0ne hourafter Lhe methylergonovine maleate (aL the Lime of Lhe subarachnoid hemorrhage) her blood sponlaneous pressure was 1701100. None of the paLienw received oxytocic stimulaLion during labor. Three of the 37 paLienLs, because of convulsions, were mistakenly diagnosed as eclatnplic and treated as such.
Comment Even though 37 cases of this rare entiLy as a cause of maternal death form a large collecLion. the authors realize that this number is still LOO small to allow sLaListica1 evaluation and dogmatic conclusions. DaLa presented suggesL that pregnancy per se has no appreciable effect upon the occurrence of the hemorrhage, but thev do seem to indicaLe that labor and delivery increase the risk of spontaneous subarachnoid hemorrhage. How LO deliver Lhe palients who sur-vive spontaneous subarachnoid hemorrhage (either by conservative therapy or by cervical carotid occlusion or intracranial
Volume Number
125 3
Table
IX-Cont’d
Case No. Sudden
Maternal
Time
severe headache and irreversible 2 5 wk. pp. 3 25 wk. 5 30 wk.
8 10
19 wk. 3 wk. pp.
11
30 wk.
12
4 days pp.
16
10 days pp.
17 20 23 24 26 27 28 29 31
35 wk. During labor at term 38 wk. 3 wk. pp. 28 wk. 40 wk. 8 wk. 5 wk. pp. 12 wk.
32
8 days pp.
34 35 36
30 wk. 1 hr. pp. 4 wk. pp.
37
3 wk. pp.
OtheFs (three fintients): 7 12 days pp.
14
25
16 Mrk.
32 wk
Neurolo&
I
coma (22 patients): Sidden severe headache Sudden severe headache Sudden severe headache convulsions and coma. at onset of headaches Sudden severe headache Sudden severe headache, few minutes, convulsions Sudden severe headache
deaths
due to subarachnoid
state
I
and coma within a few minutes and coma within a few minutes lasting 10 hr., then Refused hospitalization (house call by M.D.) and coma 4 hr. later. stiff neck, and, within a and coma with rapid coma and death
Sudden severe headache at 8 P.M. Codeine prescribed via telephone. To bed at 10 P.M. Husband found her in coma at 12 P.M. Sudden severe headache in the evening. She went to bed. Husband found her in coma in the A.M. Sudden severe headache and coma within a few minutes Sudden severe headache, slurred speech and rapid coma Sudden severe headache and coma 2 hr. later Sudden severe headache and coma within 1 hr. Sudden severe headache and coma 1 hr. later Sudden severe headache and coma within a few minutes Sudden severe headache and coma 1 hr. later Sudden severe headache and coma within a few minutes Sudden severe headache with lethargy. Hyperreflexia on right side. Then grand ma1 seizure and coma 2 hr. later Severe headache of 3 day’s duration, then grand ma1 seizure, decerebrate rigidity, and coma Sudden severe headache and coma within a few minutes Sudden severe headache and coma within a few minutes Sudden severe headache. Two hours later, convulsion and coma Sudden severe headache and coma 4 hr. later Sudden aphasia. Rt. arm and rt. side of face paralyzed. Babinski + bil. No attempt at workup by M.D. Coma 2 days before death Sudden severe headache and coma for 1 day, then became conscious. Left third nerve palsy. Complete dysphasia. Rt. hemiparesis. Aphasia. Twelve days after original symptoms arteriogram showed rupt. aneurysm. Surgery done, but pt. died 2 days p.o. Sudden severe headache. Disoriented. Convulsion. Marked nuchal rigidity. Conservative treatment. Coma and death 11 days after original symptoms
surgery) has received much discussion in the literature. Most authors29 4* 5* ‘, 8* lo-l3 agree that there appears to be no indication for cesarean section unless there is an obstetric or fetal indication. Cesarean section per se is no guaramee that an aneurysm or arteriovenous malformation will not rupture. Daane and Tandy” reported one documented recurrent hemorrhage due to ruptured berry aneurysm occurring during cesarean section. Pedowitz and Pere114 reported one probable rupture of a berry aneurysm occurring during elective cesarean section. Also, Copelan and Mabon7reported a case of a massive subarachnoid hemorrhage due to
hemorrhage
Duration
389
of life
2-E hr. 14 hr. 12 hr.
6 hr. 4-s hr. Immediate death (DOA) 7 hr.
17 hr. 2-G hr. 7 days 3-s hr 11 hr. 3 days and 5 hr. 3 hr. 21-G hr. 24 hr. 9 hr.
55 hr. 10-g hr 4 days 4 days 24 hr. 42 days
16 days
berry 11 days
suspected ruptured berry aneurysm occurring during elective repeat cesarean section. Excellent discussions by Amiss,” Robinson and associates,” and most recentiy in an excellent paper by Hunt and associates, I3 have been presented regarding cardiac output, venous and systemic arterial pressures, and cerebrospinal fluid pressures during uterine contractions and the pushing effort of the mother (Valsalva maneuver). All of these parameters are increased. Avoidance of the Valsalva maneuver and shortening of the second stage of labor with forceps are recommended by them. To assist in settling the issue of
390
Barn0
June
and Freeman
1. lY76
Am. J. Obstet. Gynec-01.
Table
X. Method
subarachnoid
of deliver!.
Table
spontaneous
hemorrhage,
Minnesota.
ISfiU-
1973
XI.
Outcome
spontaneous
of infant,
subarachnoid
Inatcrnal
deaths,
hemorrhage.
hlinnesota,
l%O-1973 Spontaneous lmw forceps Cesarean section Low segmenr for fetal salvage Repeat classical at 37 \vk. (I) U&Iivered* Total *.l‘hree surviving
of these had postmortem infants.
cesarean
se&on
vs. vaginal
cerebral
vascular
pressures
nancy, section
( 1) 15 3
labor, before
tesarean
delivery, are
- 41 101
sections
studies
needed
and vaginal deliver). and a final definitive answer
with
57.x 2.6
42,2
x I 100.0
no
of inua-
during
L)O* -1 I3 T-ii
Living and well Stillborn (860 grams) Undeliverecl l‘otal
preg-
during cesarean is available.
PaLienrs arachnoid Lhey merit
\vho
have
survived
hemorrhage
should
are
be carefully
by obstetricians
.t
spontaneous
in a high-risk monitored.
and
sub-
calegory Team
neurosurgeons
and
manage-
is indicated.
REFERENCES
I. Conley, J. W., and Rand, C. W.: Arch. Neural. Psychiat. 66: 443, 1951. 2. Cannell, D. E., and Botterell. E. H.: Ah*. J. OBSTE.T. GYNECOL. 72:844, 1956. 3. Smolik, E. A., Nash, F. P.. and Clawson, J. W.: South. Med. J. 50: 561. 1957. 4. Pedowitz. P., and Perell, A.: AM. J. OBSTET. GYNECOI.. 73: 736, 1957. Cannell. D. E.: Proc. R. Sot. Med. 52: Y50, 1959. Z: Daane, T. A., and Tandy, R. W.: Obstet. Gynecol. 15: 305. lY60. 7. Copelan, E. L.. and Mabon, R. F.: Obstet. Gynecol. 20: 373, 1962. x. Spencer, W.: J. Mt. Sinai Hosp. N’. y. 31: 487. 1064.
Discussion
Table
DR. JAMES A. O’LEARY, Chicago, Illinois. This paper does not lend itself 10 statislical analysis; it is simply a compendium of dala which challenges review. The paper is a good follow-up to Dr. Barno’s prior publication on maternal mortality. The bibliography is flawless and very representative. The paper is succinct and well presenred. Since Ihe death certificate dala lvere so inaccurate, can were
we be sure equally
Lhac the II should were
chat
the
olher
as unreliable
paCent
during
that
merhods
and
distribution
be noled
detected
Y. Pool, J. L.: J. .4. M. A. 192: 2OY, lY65. 10. Fliegner, J, R. H.. Hooper, R. S., and Kloss. M.: Gynaecol. Br. Commonw. 76: 912, 1969. Il. Amiss. A. G.: J. Ohster. Gynaecol. Br. Commonw. 100, 1970. 12. Robinson, J. L., Hall. C. J., and Sedzimir, C. Neurosurg. 36: 27, 1972: 41: 63, lY74. 13. Hunt, H. B.. Schifrin, B. S., and Suzuki. li.: Gynecol. 43: 827, 1974. 14. Maternal Mortality Committee, .Llinn. Sta~c Med. Minn. Maternal Mortality Study, 1950 Study, Minn. 36: 609, 1953. 15. Barno, A., Freeman, D. W., and Bellville, 7’. P.: Gynecol. 9: 336, 19.57.
might the the
largesl period
of surveillance
lherefore
ii is possible
be entirely number of
greatest
different. of deaths surveil-
lance. If their methodology is accurate, then perhaps il should be used by all. There are no real issues to argue with as wc have simply been presenled with 37 mothers who died from a spontaneous event. Thus we canno( determinr incidence figures, prevalence rales, or even survival rales. One paGent was known 10 be hypertensive and should be excluded from a study of .spor~tnr~o~
I. Maternal
Obstct. 77: B.: J. Ohstet, Assoc .: Med. Obstet.
age
>
15-19 20-24 25-29 30-34 35.3Y 40-44 4Ci+
18.55 33.4 28.X 13.08 4.47 I I3 0.056
14.64 33.x 31.x 13.89 4.48 1.14 0.055
5.0 14.0 22.0 32.0 16.0 1 1 .o
5.6X 1 Y.57
27 .59
Another palienl afler a dose of also be excluded.
developed intravenous
35 or older (%) 30 or older (%) x&, = 30.9 P = < 0.005
subarachnoid significant methergine IniCally pregnancy the risk.
hemorrhage. hvpertension and should lhere
is
an
has no effect,
apparenl yet labor
conlradi&on, and
delivery
i.c., increase
Volume Number
125 3
The facts that the incidence of this disease is the same in men and women, and that these patients had 106 prior pregnancies, suggest that pregnancy may not be an important factor. Perhaps it is the maternal age. If pregnancy has no effect, the parity distribution in this group should reflect the statewide parity in Minnesota. Is this comparative information available? Our statistical analysis of the maternal age of Dr. Barno’s cases (Table I) shows high statistical validity (p = < 0.0005) for the analysis of maternal age as it compares with the number of patients with subarachnoid hemorrhage. Thus it can be concluded that increasing age is a primary determining factor in the incidence of this problem in pregnancy and women over 30 years of age. DR. LEE B. STEVENSON, Detroit, Michigan. The need for uniform terminology in dealing with maternal death is evident in the opening remarks concerning materials and methods. In Michigan, we also use the 3 months or !)O days limit after termination of pregnancy in identifying a maternal death. But Oh&t?%Gynecologic Trrminolog?i for the purposes of “world statistical evaluation” defines maternal death as “the death of any woman, from any cause, while pregnant or within 42 days of the termination of pregnancy, irrespective of the duration and the site of pregnancy.” These 42 days are further divided into “Period I: 1 to 7 days following termination of pregnancy,” and “Period II: 8 to 42 days following termination of pregnancy.” At least one of the deaths in this study would have been omitted with the 42 day limitation. One patient was excluded from the Michigan study because she survived, com.atose, for more than a year after the hemorrhage occurred in a military hospital in the southwest. Terminology variants continue in the discussion of results with “obstetric” and “nonobstetric” instead of “direct maternal death,” defined as “an obstetric death resulting from obstetric complications of the preg.nancy stale, labor, or puerperium-from interventions, omissions, incorrect Creatment, or a chain of events resuhing from any of the above, and “indirect maternal death” defined as “an obsletric death resulting from previously existing disease, or disease thai developed during pregnancy, labor, or the puerperium; it is not directly due to obstetric causes, bm aggravated by the physiologic effects of pregnancy.” In a review (Table I) of the dala from Michigan for the 10 year period 1965 to 1974, there were 25 of 57 cerebral hemorrhage deaths attributable to sponlaneous subarachnoid hemorrhage. Toxemia accounted fol 42 per cent, and the other classifications are similar to Dr. Barno’s excepl for the two deaths attributable to hemorrhage secondary to adminisLraLion of Ergotrate. The conspicuous goal that this paper accentuates is a combination or pooling of data from a bigger base
Maternal deaths due to subarachnoid hemorrhage
391
Table I. Maternal deaths due to cerebral hemorrhage, Michigan, 1965-1974 Cause Spontaneous subarachnoid (Berry aneurysm and A-V Malformation Toxemia Eclampsia and Preeclampsia (16) HCVD with functional increment (4) HCVD without functional increment (4) Brain tumor Secondary to ergot Invasive mole Leukemia Sinus thrombosis DIC
No.
PPT cent
25
44
24
42
2 2 1 1 1 1
3 i 2 2 2
with the use of common terminology and methodology. Dr. Tom Leonard, Chairman of the Wisconsin Maternal Mortality Study Committee, is seeking cooperation wilh a plan to consolidate statistical daLa from each of the constituent states of District VI of the American College of Obstetricians and Gynecologists. Not only would this increase the data base, bm it could aid in identifying trends in maternal deaths with the opportunity for a quicker response to new problems. George Ryan from Boston is seeking funds for a consolidated study, possibly national in scope, through the American College. The Central Association of Obstetricians and Gynecologists is the natural parem for such a worthwhile endeavor. Most of the effective existing studies have adopted potent approaches to case idenlification and study. Many different methods of utilizing and disseminating results are available. More can be developed. But first the “who” in each existing study must be located and convinced to cooperate or find someone who can. The natural repository is a Central computer. With this approach, 300 cases could be the basis for this study inslead of the 37 reviewed. SIR LANCE TOWNSEND, Parkville, Victoria, Australia. I agree with the last speaker about pooling results. I think it would be quite interesting if I could give you our statistics for the last 6 years in the Commonwealth of Australia. During LhaL period we had 1,382,5 13 births, which number is a little less than the 24 year period about which Dr. Barno has told us. And during that time we had 512 deaths. Cerebral hemorrhage as a blanket diagnosis was the most frequent cause of maternal death. We had during this period 56 deaths from cerebral hemorrhage, 28 were associated with eclampsia, four from other causes, and 24 from ruptured Berry aneurysm. I do no1 think Dr. Barno should worry about the inadequacy of his
392
Barno
and Freeman
investigation, because of our figure of maternal deaths due to this condition is practically the same as his. DR. ROBERT C. STEPTO, Chicago, Illinois. This subject, we feel, is very much involved with the low socio-economic group and the high-risk patient. In Chicago, at Cook County Hospital, of 93,5 13 live births during a period of seven years, there were 55 direct obstetric deaths and 33 associated with indirect obsLetric deaths. Of‘ these, three deaths were associated with subarachnoid hemorrhage. Our concern, however, is not so much these three cases, but the fact that within the past year, we have seen six cases of cerebral hemorrhage, both associated with intraventricular hemorrhage and with aneurysms. The problem Lhat we have is how, with this retrospective dala, to serve some point of evalualion of the hemorrhage patients. I think that from the dala thaL were presented by Dr. Barno and from our review of the literature of 178 cases and our personal experience that perhaps we need to set some sort of working protocol for the managemem of these patients. DR. BARM~ (Closing). Regarding Dr. O’Leary’s comment about parity distribution, we are concerned about this. We asked the State Health Department to document for LIS the order of birth for these 1,700,OOO live births. They said lheir computer system had not been set up, so we could not get this data; but ic will be forthcoming sometime. As far as the death certificate inaccuracies, I am sure that in spite of what we have set up, we are still missing some maternal deaths, especially concerning those dying undelivered, since there is no baby LO check against in our cross-match technique.
June 1. 1976 Am. J. Obstet. Gynecol.
Now, in answer to Dr. O’Leary’s comment about the paradoxical siLuation--that pregnancy, per se, has no effect, vet labor and delivery do. With only one previous case in the literature occurring during labor and delivery among the 145 or so reported thus far, we felt that our five occurring during labor and deliver! certainly warranted reporting. It caused us concern. We gave the data to our biostatisticians, and at first, they said they would like 10 have 50 cases, then said they would like 200 LO be definite about theirconclusions. In any event, it was their opinion that WI conclusions were logical. Concerning Dr. O’Leary’s comment, all but one (Jf the patients were normotensive before the tragic episode of spontaneous subarachnoid hemorrhage (one who had hypertensive vascular disease). Jusr because a patient has hypertensive vascular disease. is no reason why she can’t also have a berrv aneurysm (as our case did and was proven by autopsy). Regarding the patient who had the intravenous methylergonovine maleate, she also was normotensive before the injection. I discussed this situation in the paper with regard to the fact that this artificially produced hyperlension might have been a factor in causing the rupture of her Berry aneurysm. I wish to re-emphasize the inaccuracy of the death certificates for the entire 843 maternal deaths for this 24 vear period-20 per cent were wrong. The cause of‘ death on the death certificate and that determined bv the Committee had no correlation. Checking the birth certificates, the data are just a little more accurate.
BARNO,
M.D.
D. W. FREEMAN, Minneapolis,
M.D
Minnesota
Spontaneous subarachnoid hemorrhage due to ruptured berry aneurysm and arteriouenous malformation accounted for 4.4 per cent of all maternal deaths in the State of Minnesota,from 1950 to 1973. This catastrophic entity ranked eighth in frequency regarding all causes of death and third among the nonobstetric causes. An analysis of the 37 deaths among 1,763,824 live births is pesented. These 37 patients had delivered 96 infants and had 10 spontaneom abortions prior to current pregnancy. Thic suggests that of the hemorrhage. Five pregnancy per se has no app-Pciub~e effect upon th e occurrence of these died in association with labor and delivery, or during a 1 da! period-three during labor, one dun’ng vaginal delivery. and one only 1 hour postpartum. This is equivalent to 35 per week. On the other hand, 15 occurred during pregnancy (undelivered) (0.4 per week) and 17 during thejrst 3 months post partum (-1.4 pn week). The.ye data seem to indicate that labor and deliveq increase the risk of spontaneous suba.rachnoid hemomhage. The neurologic state of these 37 patients ulas bad from the very onset of the hemorrhage. Rapid irreversible coma occurred in 34 (76 per cmt). Oj these 34, 23 (74 per rent) were dead within the$r.st 24 hours and 32 (94 per cent) were dead zoithin the first 4 days following the onset qf the hemorrhage.
IT IS THE PURPOSE of this paper to analyze the maternal deaths due to spontaneous subarachnoid hemorrhage which occurred in the State of Minnesota for a 24 year period, 1950 CO 1973. These were deaths due to ruptured berry aneurysm and arteriovenous malformation. Isolated case reports, series, and composite series of cases occurring during pregnancy and the postpartum period have appeared in ~hc literature’-l3 but it is the opinion of the authors thal this accumulalion of a large series of 37 deaths with detailed study warrants reporting.
state to study the hospital record, the prenatal record. and interview the physicians and all other persons involved in the management of every maternal death. All deaths associated with pregnancy and the 3 month postpartum period are investigated. The data are then presented in protocol summary to the Minnesota Maternal Mortality Committee-23 members representing the entire state. Final decisions are then made as to the cause of death, criticism of handling of the case as to care being adequate, faulty and contributor) to death, or faulty and not contributory with regard to prenatal care, labor and delivery and postparwm care. Analysis is made of the autopsy, completion of the death certificate, the birth and/or death certificate of the infant, and final assessment is made as to the prevenlability of death and responsibility for the death. The protocols of the 37 deaths due to spontaneous subarachnoid hemorrhage were carefully analyzed.
Materials and methods The data were obtained from the Minnesota Maternal Mortality Study which has been a continuous one since 1950. Previous publications 14, l5 have elucidaled the mechanics of the study. Suffice it to say that Board-certified obstetricians travel throughout the
Rssults From the Minnesota
Maternal
Morfality
Stud!.
The 37 deaths births resulted in an incidence births, or 1.5 per year. During (1950 to 1973) there were a d(:aths-483 obstetric (where Incidence.
Presented at the Forty-third Anwal Meeting of thr Central Association of Obstetricians and Gynecologists, Colorado Spings, Colorado, September 26-28, 1975. Reprint reqwrts: Dr. Alex Barm, Minneapolis, Minnesota 555316.
5000 W. 39th St., 384
among 1,763,824 live of one per 47,671 live this 24 year period total of 843 maternal pregnancy played a
Maternal deaths due to subarachnoid hemorrhage
Volume Number
125 3
Table
I. Maternal
deaths, Minnesota,
Came
1
Obstetric hemorrhage Obstetric infection* Trauma Toxemia Heart disease Malignant tumors Amniotic fluid embolism Spontaneous subarachnoid hemorrhage Not determinable Chorionepithelioma Poliomyelitis Anesthesia Peritoniti:i Air embolism Pneumonia Infectious hepatitis Leukemia Transfusion deaths Diabetes mellitus Glomerulonephritis Dehydration and electrolyte imbalance Coronary occlusion Bronchial asthma Ruptured aortic aneurysm Others Total *Includes
pulmonary
1950-1973
NO.
1
Per cent
119 98 95 68 49 45 39 37
14.1 11.6 11.3 8.1 5.8 5.3 4.6 4.4
36 26 25 20 19 16 11 8 8 7 6 5 5
4.3 3.1 3.0 2.4 2.3 1.9 1.3 0.9 0.9 0.8 0.7 0.6 0.6
5 5 5 86 843
0.6 0.6 0.6
10.2 100.0
embolism.41
causitive role) and 360 nonobstetric. Table I shows a breakdown of these 843 maternal deaths as to primary causes (both obstetric and nonobstetric). It is seen that this catastrophic entity ranked eighth in frequency regarding all causes of death and third among the nonobstetric causes. All of these patients were normotensive before the tragic episode of spontaneous subarachnoid hemorrhage except for one. She was a 42-year-old para 3 who had hypertensive vascular disease and died during labor at 31 weeks’ gestation. Autopsy showed a ruptured berry aneurysm. There was no history of trauma in any of these 37 patients and none had had a previous subarachnoid hemorrhage. Table II shows that, of all the maternal deaths due LO cerebral hemorrhage for the 24 year period under consideration, spontaneous subarachnoid hemorrhage due to ruptured berry aneurysm and arteriovenous malformation accounted for 51 per cent. Toxemias accounted for 35 per cent and the remainder as enumerated. Source of reporting. The mechanism via which these deaths were discovered is shown in Table III. Had reliance been placed on death certificate information alone, one half of these cases would have been missed, since pregnancy or the postpartum state was not recorded on the death certificate in 18. Eight were
385
Table II. Maternal deaths due to cerebral hemorrhage, Minnesota, 1950- 1973 Came
NO.
Per cent
Spontaneous subarachnoid (Berry aneurysm and A-V malformation) Toxemia Eclampsia and pre-eclampsia (16) Hypertensive vascular disease with functional increment (5) Hypertensive vascular disease without functional increment (4) Choriocarcinoma
37
51
25
35
Brain tumor (astrocytoma) Thrombocytopenic purpura Myelomonocytic leukemia Hypersplenism Autoimmune disease Total
Table III. Source of reporting, spontaneous subarachnoid hemorrhage, Minnesota, 1950- 1973 Source Death
certificate
No.
Per cmt
19
51
18
49
(complete and correct) Other sources* X-match (8) Hospital record room (4) Other physicians (3) Field investigator (2) Original physician. (1) Total *Pregnancy certificate.
or postpartum
37 state not
mentioned
100 on death
discovered by the cross-match (x-match) technique. The Vital Statistics Section of the Minnesota State Department of Health pulls all death certificates of women aged 15 through 45 and for each of these, searched for a birth or fetal death certificate. The other 10 were discovered as enumerated in Table III. Of these 10, eight would have been picked up by the x-match technique but two would have been missed since they died undelivered. Regarding all the maternal deaths (843) during the 24 year period under consideration ( 1950 to 1973), one third would have been missed since pregnancy or the postpartum state was not recorded (Table IV). Thus, reports in the literature regarding the incidence of spontaneous subarachnoid hemorrhage as a cause of maternal death, based on death certificate information, are inaccurate. “Committee efforts” warrants elucidation. Before the Minnesota Maternal Mortality Study was begun, all physicians and hospitals in the state were notified-the physicians via communication in Min-
386
Barno and Freeman
Table
IV.
Minnesora,
Source of reporting, 1950- 1973
maternal
cleaths,
s o,ltTI’ Death certihcate Commirtec efforts
*Not included as a marernal death in viral statistics. V. Age, spontaneous subarachnoid hemorrhage, Minnesota. 19% 1978
Table
,4ge
Table
VI.
spontaneous 1950-1973
Parity (excluding suharachnoid
r~cotn M~ciicit~,
so.
Per WNf
present pregnancy). hemorrhage, Minnesota.
the stale medical journal, and via ihe from the Stale Medical Association and the hospitals via letters. As the study unfolded and has been publicized in medical circles, information regarding maternal deaths is being presented lo the committee by the physicians involved, other interested physicians, nurses, social workers, and medical record-room personnel. The field investigators have discovered cases thal would have been missed b? inquiring a~ hospitals regarding other maternal deaths thal might have occurred. The x-match technique has already been described. Information is also obLained b) auditing newspaper reports. The authors are of the opinion that in spite of all of this, some maternal deaths are still being missed, especially of those who die undelivered. Autopsies. Documentaion of’ these cases was excel121rdical
Nrwskttu
lent. ‘I‘wcnty-nine (78 per cent) had autopsies, ittclutiittg the head. In the other eight (29 per cent) rhc diagnosis was ~nacle on lhc basis of histor), c,linical findings. bloody spinal tap, elevated spinal fluid pressure, and/or artrriogt-aphv. Kegarding the 2!) autopsies, a ruptured berrv aneurvsm was ti~utltl in 13, artertovenous malfortn;~tion in foyer. and in ten hentot rhage was so rttassivts aiitt slt~uc~turos so descrovt~tl (vessels and surrounding brain tissue) that identifica(iott of the aneurysm US impossible. Of the fi)ttt arteriovcnous ttt;tlfortnatiotrs, these occur-t-& a( 7 davs post parntm. ZSweeks post parcum. 8 weeks’ gesiatiott (ttntlrliverrd). atltl 12 \+ccks’ gr‘station (tlntlelivctt,c,tl). Age and parity. As seen in .I‘ahle L’. one thircl c)f these patients wcrc in 1he 50 to 3.4 year age group. 1, ilh the secot~ti largest number (22 per c‘cn~) ilt the 2.5 to Z!j calegorv. Parity (esc litding present pregtlallcv) is sutnmarized ii, Tat+ VI. ~I‘hesc 37 pti~lllY hat1 deliverc~d 96 irtf’&lls and had had IO spontaneous aborciotts print LO current prcgnant~y. ~I‘his .ruggests that pt-egnancv per SC has IIO appreciable effect upott ht. occurrent c of the cnrit\ Time of occurrence. fable VII presrnrs a11 analysis regarding the time of’ occurrence of 01~ subarachnoid hemorrhage. Almost one half of these occurre(l during lhc posIparLum stale :III~ 11 per- cc~it in lhc undelivered. Of the I5 utndelivered. IO (Iwo thirds) occ urrtyl in Lhe last trimc.ster. .L\ most significattt fittdiiig was that in four paticnls the episode occurred during labor OI vaginal clelivt~r\.. Hunr and associales’” in a recrrll publication. stared. ” 1‘0 our knowledge. onlv ant’ hemorrhage from a tlocumenLed ancur~sm has been reported (luring labor or \.aginal tieli\:er\:.‘~ l;ivc patients in this series died in association \vith lahor ;IIKI deliver>-. or during a I day periotl--thrcyi during labor, one during vaginal deliver\. and OllV only 1 hOll1 poslpartutn. ‘l‘his is equivalent IO 3.5 [ICI’ keel\. 011 cht, other hand, 15 occttrrrtl during pregnancy (undelivered) (0.4 per week) a~td 17 during rhc :< ntonths postpartum ( 1.4 per \veck). .I‘hesr: data seem IO itttlical(’ that labor and deliver-\ increase the risk of spontant*otts subarachnoid hemorrhage. Duration
of
life
after
spontaneous
subarachnoid
[‘hat this is a catastrophic entity is illust.raled b\, the fact that 68 per cent of these patieltrs died withit? Ihe first 24 hours of Ihe occurrence of (ht. hemorrhage.
helllorrhagc,
86 per
WILL died
within
4 days.
and
93 per.
wilhitt I1 clays (Table VIII). Most of the patietttx in [his herirs died brfi1t.c surgel-1 c~ould I)c c onsitlered. Only IWO wc‘rc’ subjected IO surger!. ‘I‘he first \V;LS ‘I Z-year-old para Y who had spontaneous subarachnoid hetnorrhagc AI I6 \\ecks’ gestation. .4ngiograph\ i L’ cent
d2lks
Iillrr
shc~~\ctl
2 bcl-ry
alleUwsrn
extending
off
the
Volume Number
125 3
internal carotid artery in the region of the anterior choroid artery and posterior communicating artery. Craniotomy under hypothermia anesthesia was performed 2 days later-the carotid was clipped proximal and distal to the aneurysm and a clip was placed on the neck of the aneurysm. She died 2 days postoperatively. The second patient was a 41-year-old para 8 who developed spontaneous subarachnoid hemorrhage during labor at term. She was delivered by low forceps extraction. Even though the patient was in a coma, carotid angiography was done and this showed an aneurysm of the middle cerebral artery. The neurosurgeons elected to perform craniotomy 1 week following the hemorrhage even though the patient had remained in coma but she died a few hours postoperatively. IL is not the intention of the authors to dwell on the neurosurgical treatment. This has been adequately covered by Pools and others. The basic principles are supportive therapy then, as the condition of the patient warrants, angiography for diagnosis and then surgery as indicated. Neurologic state. The neurologic state of these 37 patients was bad from the very onset of the spontaneous subarachnoid hemorrhage and the prognosis was grave, as indicaled in Table IX. Rapid irreversible coma occurred in 34 of these patienls (including Lhe two who were found dead after having complained of severe headache) (76 per cent). Of these 34 patients, 25 (74 per cent) were dead within the first 24 hours and 32 (94 per cent) were dead within the first 4 days following the onset of the hemorrhage. The condition of the patients was so grave LhaL diagnostic arteriography could no1 be done and certainly they were in no condition for surgical treatment. The neurologic state of Lhe other three patients is self-explanatory (Table IX). The mosL common symptom presenled by the patients was sudden excruciating headache. This occurred in 26 of the 37 patients (70 per cent). 1~ is not the intention of Ihe authors to try to statistically analyze the various other neurologic findings present in addition to the coma. Twemy-four of the 37 patients had spinal fluid taps. Twenty-two of lhese were grossly bloody and two were xanthochromic. In 14, the cerebrospinal fluid pressure was measured-markedly elevated in 13 and normal in one. Method of delivery. Twenty (55 per cent) were delivered via the vaginal rouLe (Table X). Two patients were delivered by cesarean section. One was a 21year-old primigravida with spontaneous subarachnoid hemorrhage occurring during labor at 40 weeks’
Maternal deaths due to subarachnoid
hemorrhage
387
Table VII. Time of occurrence, spontaneous subarachnoid hemorrhage, Minnesota, 1950-1973 Timp
Postpartum 1 hour (1)
1
No.
1
Per cent
18
48.6
15
40.5
4 days (1) 7-10 days (4) 12 days (1) 3-4 wk. (5)
5-9 wk. (5) 12 wk. (1) Undelivered (no labor) First trimester (2) Second trimester (3) Third trimester ( 10) During labor During vaginal delivery Total
Table VIII. subarachnoid
3
8.1
1 37
2.7 99.9
Duration of life after spontaneous hemorrhage, Minnesota, 1950- 1973 Time
NO.
Per cent
First 24 hours Immediate (DOA) (1) I5 minutes (2) 2-4.5 hr. (6) 6-9 hr. (5) lo-12 hr. (5) 14-17 hr. (3) 21-24 hr. (3)
25
67.6
3 4 3
8.1 10.8 8.1 2.7 2.7
44-55 hr. 3-4 days
6-l 1 days 16 days 42 days Total
1 1 37
100.0
gestation with the cervix 5 cm. dilated. Low-segment cesarean section was done under local anesthesia for fetal salvage since the patient was in coma and considered to be moribund. A normal infant weighing 6 pounds, 8 ounces was obtained. Her total labor had been 11 hours. The other patienL was a 3%year-old para 3 who was delivered at 37 weeks’ gestation by repeat classical cesarean section. Spontaneous subarachnoid hemorrhage occurred at 29 days postpartum. Of the 15 patients who died undelivered (40 per cent), three had postmortem cesarean sections with no surviving infants. Outcome of infant. The fetal mortality rate is shown in Table XI. IL is high, as we would expect (42 per cent), but it is amazing that 58 per cent of these infants survived. Other data. All of these patients were Caucasian excepl for two Negroes. The 1970 population of Minnesota was 3,805,069, with 98 per cent Caucasian
388
Barno
June
and Freeman Am. J.
Table IX. Neurologic state correlated with time of occurrence subarachnoid hemorrhage, Minnesota, 1950- 1973 the ,\‘o. R’ot feeling I
13
22 33
Found
9 I .i 19 30
coma (six putze,,ts): During delivery at 40 wk. 33 wk.
3 wk. pp During labor at 31 wk. 7 days pp. 9 days pp.
Sudden severe headache and found I8 34 wk. ?I
of life after spontaneous
statr
restless, then ,found it1 irrrurrsihle coma (four patients): 12 wk. pp. Pt. called husband at I 1 A.M. about not feeling well and being restless. He came home I% hr. later and found her in coma 9 \vk. pp. Didn’t feel well and restless. Short time latrrhusband found her with gasping respirations and in coma 7 wk. pp. At 4 A.M. became restless. Few minutes later husband heard a fall and found her in coma on the floor During labor 41 5:30 P.M. patient becatne restless and confused. at 40 wk. Cervix S-cm. dilated. .4t 6:25 P.M. developed convulsions and coma
iu meverszble 4 ti
Nru7obgi~
Tk ~4,
and duration
1. 1976
Obstet. Gynecol.
8 wk. pp.
Cy~lo anesthesia for outlet forceps. Never- regained consciousness Pt. awakened in A.M. and asked for glass of milk. 0n his return with the milk, husband found her in coma Husband found her comatose in basement at 5: I.5 P.M. Pt. in earlv labor. At routine check nurse found her with cyanosis and in coma Found in coIna in bathroom by her childrrll Collapsed while walking downstairs. Found in coma by husband
&ad (two patier&): Severe sudden headache and went to bed at 8 P.M. Husband found her dead at 3: 15 A.M. next morning Sudden severe headache. Husband went to drug store fi~r analgesic-. On his return he fnund her dead on the floor
and 2 per cenL non-Caucasian-Negro, 0.9 per cent; Indian, 0.6 per cenL, and others, 0.5 per cent. Carotid angiograms were performed on four patients and an aneurysm was demonslrable in each. Associated disease was present in nine of these 37 patienLs--obesity in four (190, 212, 235, and 246 pounds), polycysLic kidney disease, alcoholism with multiple sclerosis, congenital Lorticollis, peLi1 mal epilepsy, and M&&e’s disease. As previously noted, all of Lhese patients were normotensive before the episode except one. After the episode of spontaneous subarachnoid hemorrhage Lhe blood pressure was elevaled in 19, normal in nine, at shock levels in three, and no1 recorded in six. The increase in blood pressure is due Lo the increased intracranial pressure. The case protocols were perused as to whether the administration of oxyLocic drugs might have contributed to the rise in blood pressure. This was so in only one insLance. This patient received 1 c.c. of methylergonovine maleate (Methergine. Sandoz), 0.2 mg. intravenously, afLer the delivery of the placenta because of uLerine atony (400 c.c. estimaLed blood loss). She was normotensive before spontaneous
7 hr. I5 min.
delivery. One half hour afLer Lhe meLhylergonovine maleate, her blood pressure rose Lo 160/W. 0ne hourafter Lhe methylergonovine maleate (aL the Lime of Lhe subarachnoid hemorrhage) her blood sponlaneous pressure was 1701100. None of the paLienw received oxytocic stimulaLion during labor. Three of the 37 paLienLs, because of convulsions, were mistakenly diagnosed as eclatnplic and treated as such.
Comment Even though 37 cases of this rare entiLy as a cause of maternal death form a large collecLion. the authors realize that this number is still LOO small to allow sLaListica1 evaluation and dogmatic conclusions. DaLa presented suggesL that pregnancy per se has no appreciable effect upon the occurrence of the hemorrhage, but thev do seem to indicaLe that labor and delivery increase the risk of spontaneous subarachnoid hemorrhage. How LO deliver Lhe palients who sur-vive spontaneous subarachnoid hemorrhage (either by conservative therapy or by cervical carotid occlusion or intracranial
Volume Number
125 3
Table
IX-Cont’d
Case No. Sudden
Maternal
Time
severe headache and irreversible 2 5 wk. pp. 3 25 wk. 5 30 wk.
8 10
19 wk. 3 wk. pp.
11
30 wk.
12
4 days pp.
16
10 days pp.
17 20 23 24 26 27 28 29 31
35 wk. During labor at term 38 wk. 3 wk. pp. 28 wk. 40 wk. 8 wk. 5 wk. pp. 12 wk.
32
8 days pp.
34 35 36
30 wk. 1 hr. pp. 4 wk. pp.
37
3 wk. pp.
OtheFs (three fintients): 7 12 days pp.
14
25
16 Mrk.
32 wk
Neurolo&
I
coma (22 patients): Sidden severe headache Sudden severe headache Sudden severe headache convulsions and coma. at onset of headaches Sudden severe headache Sudden severe headache, few minutes, convulsions Sudden severe headache
deaths
due to subarachnoid
state
I
and coma within a few minutes and coma within a few minutes lasting 10 hr., then Refused hospitalization (house call by M.D.) and coma 4 hr. later. stiff neck, and, within a and coma with rapid coma and death
Sudden severe headache at 8 P.M. Codeine prescribed via telephone. To bed at 10 P.M. Husband found her in coma at 12 P.M. Sudden severe headache in the evening. She went to bed. Husband found her in coma in the A.M. Sudden severe headache and coma within a few minutes Sudden severe headache, slurred speech and rapid coma Sudden severe headache and coma 2 hr. later Sudden severe headache and coma within 1 hr. Sudden severe headache and coma 1 hr. later Sudden severe headache and coma within a few minutes Sudden severe headache and coma 1 hr. later Sudden severe headache and coma within a few minutes Sudden severe headache with lethargy. Hyperreflexia on right side. Then grand ma1 seizure and coma 2 hr. later Severe headache of 3 day’s duration, then grand ma1 seizure, decerebrate rigidity, and coma Sudden severe headache and coma within a few minutes Sudden severe headache and coma within a few minutes Sudden severe headache. Two hours later, convulsion and coma Sudden severe headache and coma 4 hr. later Sudden aphasia. Rt. arm and rt. side of face paralyzed. Babinski + bil. No attempt at workup by M.D. Coma 2 days before death Sudden severe headache and coma for 1 day, then became conscious. Left third nerve palsy. Complete dysphasia. Rt. hemiparesis. Aphasia. Twelve days after original symptoms arteriogram showed rupt. aneurysm. Surgery done, but pt. died 2 days p.o. Sudden severe headache. Disoriented. Convulsion. Marked nuchal rigidity. Conservative treatment. Coma and death 11 days after original symptoms
surgery) has received much discussion in the literature. Most authors29 4* 5* ‘, 8* lo-l3 agree that there appears to be no indication for cesarean section unless there is an obstetric or fetal indication. Cesarean section per se is no guaramee that an aneurysm or arteriovenous malformation will not rupture. Daane and Tandy” reported one documented recurrent hemorrhage due to ruptured berry aneurysm occurring during cesarean section. Pedowitz and Pere114 reported one probable rupture of a berry aneurysm occurring during elective cesarean section. Also, Copelan and Mabon7reported a case of a massive subarachnoid hemorrhage due to
hemorrhage
Duration
389
of life
2-E hr. 14 hr. 12 hr.
6 hr. 4-s hr. Immediate death (DOA) 7 hr.
17 hr. 2-G hr. 7 days 3-s hr 11 hr. 3 days and 5 hr. 3 hr. 21-G hr. 24 hr. 9 hr.
55 hr. 10-g hr 4 days 4 days 24 hr. 42 days
16 days
berry 11 days
suspected ruptured berry aneurysm occurring during elective repeat cesarean section. Excellent discussions by Amiss,” Robinson and associates,” and most recentiy in an excellent paper by Hunt and associates, I3 have been presented regarding cardiac output, venous and systemic arterial pressures, and cerebrospinal fluid pressures during uterine contractions and the pushing effort of the mother (Valsalva maneuver). All of these parameters are increased. Avoidance of the Valsalva maneuver and shortening of the second stage of labor with forceps are recommended by them. To assist in settling the issue of
390
Barn0
June
and Freeman
1. lY76
Am. J. Obstet. Gynec-01.
Table
X. Method
subarachnoid
of deliver!.
Table
spontaneous
hemorrhage,
Minnesota.
ISfiU-
1973
XI.
Outcome
spontaneous
of infant,
subarachnoid
Inatcrnal
deaths,
hemorrhage.
hlinnesota,
l%O-1973 Spontaneous lmw forceps Cesarean section Low segmenr for fetal salvage Repeat classical at 37 \vk. (I) U&Iivered* Total *.l‘hree surviving
of these had postmortem infants.
cesarean
se&on
vs. vaginal
cerebral
vascular
pressures
nancy, section
( 1) 15 3
labor, before
tesarean
delivery, are
- 41 101
sections
studies
needed
and vaginal deliver). and a final definitive answer
with
57.x 2.6
42,2
x I 100.0
no
of inua-
during
L)O* -1 I3 T-ii
Living and well Stillborn (860 grams) Undeliverecl l‘otal
preg-
during cesarean is available.
PaLienrs arachnoid Lhey merit
\vho
have
survived
hemorrhage
should
are
be carefully
by obstetricians
.t
spontaneous
in a high-risk monitored.
and
sub-
calegory Team
neurosurgeons
and
manage-
is indicated.
REFERENCES
I. Conley, J. W., and Rand, C. W.: Arch. Neural. Psychiat. 66: 443, 1951. 2. Cannell, D. E., and Botterell. E. H.: Ah*. J. OBSTE.T. GYNECOL. 72:844, 1956. 3. Smolik, E. A., Nash, F. P.. and Clawson, J. W.: South. Med. J. 50: 561. 1957. 4. Pedowitz. P., and Perell, A.: AM. J. OBSTET. GYNECOI.. 73: 736, 1957. Cannell. D. E.: Proc. R. Sot. Med. 52: Y50, 1959. Z: Daane, T. A., and Tandy, R. W.: Obstet. Gynecol. 15: 305. lY60. 7. Copelan, E. L.. and Mabon, R. F.: Obstet. Gynecol. 20: 373, 1962. x. Spencer, W.: J. Mt. Sinai Hosp. N’. y. 31: 487. 1064.
Discussion
Table
DR. JAMES A. O’LEARY, Chicago, Illinois. This paper does not lend itself 10 statislical analysis; it is simply a compendium of dala which challenges review. The paper is a good follow-up to Dr. Barno’s prior publication on maternal mortality. The bibliography is flawless and very representative. The paper is succinct and well presenred. Since Ihe death certificate dala lvere so inaccurate, can were
we be sure equally
Lhac the II should were
chat
the
olher
as unreliable
paCent
during
that
merhods
and
distribution
be noled
detected
Y. Pool, J. L.: J. .4. M. A. 192: 2OY, lY65. 10. Fliegner, J, R. H.. Hooper, R. S., and Kloss. M.: Gynaecol. Br. Commonw. 76: 912, 1969. Il. Amiss. A. G.: J. Ohster. Gynaecol. Br. Commonw. 100, 1970. 12. Robinson, J. L., Hall. C. J., and Sedzimir, C. Neurosurg. 36: 27, 1972: 41: 63, lY74. 13. Hunt, H. B.. Schifrin, B. S., and Suzuki. li.: Gynecol. 43: 827, 1974. 14. Maternal Mortality Committee, .Llinn. Sta~c Med. Minn. Maternal Mortality Study, 1950 Study, Minn. 36: 609, 1953. 15. Barno, A., Freeman, D. W., and Bellville, 7’. P.: Gynecol. 9: 336, 19.57.
might the the
largesl period
of surveillance
lherefore
ii is possible
be entirely number of
greatest
different. of deaths surveil-
lance. If their methodology is accurate, then perhaps il should be used by all. There are no real issues to argue with as wc have simply been presenled with 37 mothers who died from a spontaneous event. Thus we canno( determinr incidence figures, prevalence rales, or even survival rales. One paGent was known 10 be hypertensive and should be excluded from a study of .spor~tnr~o~
I. Maternal
Obstct. 77: B.: J. Ohstet, Assoc .: Med. Obstet.
age
>
15-19 20-24 25-29 30-34 35.3Y 40-44 4Ci+
18.55 33.4 28.X 13.08 4.47 I I3 0.056
14.64 33.x 31.x 13.89 4.48 1.14 0.055
5.0 14.0 22.0 32.0 16.0 1 1 .o
5.6X 1 Y.57
27 .59
Another palienl afler a dose of also be excluded.
developed intravenous
35 or older (%) 30 or older (%) x&, = 30.9 P = < 0.005
subarachnoid significant methergine IniCally pregnancy the risk.
hemorrhage. hvpertension and should lhere
is
an
has no effect,
apparenl yet labor
conlradi&on, and
delivery
i.c., increase
Volume Number
125 3
The facts that the incidence of this disease is the same in men and women, and that these patients had 106 prior pregnancies, suggest that pregnancy may not be an important factor. Perhaps it is the maternal age. If pregnancy has no effect, the parity distribution in this group should reflect the statewide parity in Minnesota. Is this comparative information available? Our statistical analysis of the maternal age of Dr. Barno’s cases (Table I) shows high statistical validity (p = < 0.0005) for the analysis of maternal age as it compares with the number of patients with subarachnoid hemorrhage. Thus it can be concluded that increasing age is a primary determining factor in the incidence of this problem in pregnancy and women over 30 years of age. DR. LEE B. STEVENSON, Detroit, Michigan. The need for uniform terminology in dealing with maternal death is evident in the opening remarks concerning materials and methods. In Michigan, we also use the 3 months or !)O days limit after termination of pregnancy in identifying a maternal death. But Oh&t?%Gynecologic Trrminolog?i for the purposes of “world statistical evaluation” defines maternal death as “the death of any woman, from any cause, while pregnant or within 42 days of the termination of pregnancy, irrespective of the duration and the site of pregnancy.” These 42 days are further divided into “Period I: 1 to 7 days following termination of pregnancy,” and “Period II: 8 to 42 days following termination of pregnancy.” At least one of the deaths in this study would have been omitted with the 42 day limitation. One patient was excluded from the Michigan study because she survived, com.atose, for more than a year after the hemorrhage occurred in a military hospital in the southwest. Terminology variants continue in the discussion of results with “obstetric” and “nonobstetric” instead of “direct maternal death,” defined as “an obstetric death resulting from obstetric complications of the preg.nancy stale, labor, or puerperium-from interventions, omissions, incorrect Creatment, or a chain of events resuhing from any of the above, and “indirect maternal death” defined as “an obsletric death resulting from previously existing disease, or disease thai developed during pregnancy, labor, or the puerperium; it is not directly due to obstetric causes, bm aggravated by the physiologic effects of pregnancy.” In a review (Table I) of the dala from Michigan for the 10 year period 1965 to 1974, there were 25 of 57 cerebral hemorrhage deaths attributable to sponlaneous subarachnoid hemorrhage. Toxemia accounted fol 42 per cent, and the other classifications are similar to Dr. Barno’s excepl for the two deaths attributable to hemorrhage secondary to adminisLraLion of Ergotrate. The conspicuous goal that this paper accentuates is a combination or pooling of data from a bigger base
Maternal deaths due to subarachnoid hemorrhage
391
Table I. Maternal deaths due to cerebral hemorrhage, Michigan, 1965-1974 Cause Spontaneous subarachnoid (Berry aneurysm and A-V Malformation Toxemia Eclampsia and Preeclampsia (16) HCVD with functional increment (4) HCVD without functional increment (4) Brain tumor Secondary to ergot Invasive mole Leukemia Sinus thrombosis DIC
No.
PPT cent
25
44
24
42
2 2 1 1 1 1
3 i 2 2 2
with the use of common terminology and methodology. Dr. Tom Leonard, Chairman of the Wisconsin Maternal Mortality Study Committee, is seeking cooperation wilh a plan to consolidate statistical daLa from each of the constituent states of District VI of the American College of Obstetricians and Gynecologists. Not only would this increase the data base, bm it could aid in identifying trends in maternal deaths with the opportunity for a quicker response to new problems. George Ryan from Boston is seeking funds for a consolidated study, possibly national in scope, through the American College. The Central Association of Obstetricians and Gynecologists is the natural parem for such a worthwhile endeavor. Most of the effective existing studies have adopted potent approaches to case idenlification and study. Many different methods of utilizing and disseminating results are available. More can be developed. But first the “who” in each existing study must be located and convinced to cooperate or find someone who can. The natural repository is a Central computer. With this approach, 300 cases could be the basis for this study inslead of the 37 reviewed. SIR LANCE TOWNSEND, Parkville, Victoria, Australia. I agree with the last speaker about pooling results. I think it would be quite interesting if I could give you our statistics for the last 6 years in the Commonwealth of Australia. During LhaL period we had 1,382,5 13 births, which number is a little less than the 24 year period about which Dr. Barno has told us. And during that time we had 512 deaths. Cerebral hemorrhage as a blanket diagnosis was the most frequent cause of maternal death. We had during this period 56 deaths from cerebral hemorrhage, 28 were associated with eclampsia, four from other causes, and 24 from ruptured Berry aneurysm. I do no1 think Dr. Barno should worry about the inadequacy of his
392
Barno
and Freeman
investigation, because of our figure of maternal deaths due to this condition is practically the same as his. DR. ROBERT C. STEPTO, Chicago, Illinois. This subject, we feel, is very much involved with the low socio-economic group and the high-risk patient. In Chicago, at Cook County Hospital, of 93,5 13 live births during a period of seven years, there were 55 direct obstetric deaths and 33 associated with indirect obsLetric deaths. Of‘ these, three deaths were associated with subarachnoid hemorrhage. Our concern, however, is not so much these three cases, but the fact that within the past year, we have seen six cases of cerebral hemorrhage, both associated with intraventricular hemorrhage and with aneurysms. The problem Lhat we have is how, with this retrospective dala, to serve some point of evalualion of the hemorrhage patients. I think that from the dala thaL were presented by Dr. Barno and from our review of the literature of 178 cases and our personal experience that perhaps we need to set some sort of working protocol for the managemem of these patients. DR. BARM~ (Closing). Regarding Dr. O’Leary’s comment about parity distribution, we are concerned about this. We asked the State Health Department to document for LIS the order of birth for these 1,700,OOO live births. They said lheir computer system had not been set up, so we could not get this data; but ic will be forthcoming sometime. As far as the death certificate inaccuracies, I am sure that in spite of what we have set up, we are still missing some maternal deaths, especially concerning those dying undelivered, since there is no baby LO check against in our cross-match technique.
June 1. 1976 Am. J. Obstet. Gynecol.
Now, in answer to Dr. O’Leary’s comment about the paradoxical siLuation--that pregnancy, per se, has no effect, vet labor and delivery do. With only one previous case in the literature occurring during labor and delivery among the 145 or so reported thus far, we felt that our five occurring during labor and deliver! certainly warranted reporting. It caused us concern. We gave the data to our biostatisticians, and at first, they said they would like 10 have 50 cases, then said they would like 200 LO be definite about theirconclusions. In any event, it was their opinion that WI conclusions were logical. Concerning Dr. O’Leary’s comment, all but one (Jf the patients were normotensive before the tragic episode of spontaneous subarachnoid hemorrhage (one who had hypertensive vascular disease). Jusr because a patient has hypertensive vascular disease. is no reason why she can’t also have a berrv aneurysm (as our case did and was proven by autopsy). Regarding the patient who had the intravenous methylergonovine maleate, she also was normotensive before the injection. I discussed this situation in the paper with regard to the fact that this artificially produced hyperlension might have been a factor in causing the rupture of her Berry aneurysm. I wish to re-emphasize the inaccuracy of the death certificates for the entire 843 maternal deaths for this 24 vear period-20 per cent were wrong. The cause of‘ death on the death certificate and that determined bv the Committee had no correlation. Checking the birth certificates, the data are just a little more accurate.
