Maternal deaths associated with hypertensive disorders of pregnancy: a population-based study

There were 507 deaths associated with hypertensive disorders of pregnancy (eclampsia, preeclampsia, and chronic hypertension) in South Africa over the triennium 1999-2001. Eclampsia was associated with 289 deaths preeclampsia with 139, and the remaining 79 with chronic hypertension, hemolysis, elevated lever enzymes, and low platelet count (HELLP) syndrome, liver rupture and acute fatty liver. The major final cause of death was intracranial hemorrhage. Other causes included the HELLP syndrome and liver rupture. Contributory causes included pulmonary edema, renal failure/impairment, and disseminated intravascular coagulation. Deaths from eclampsia occurred at all levels of health care, in particular, there was still a considerable number of deaths at level I hospitals. Most deaths from eclampsia occurred at low parity (parity 0 = 51%), while 13% of deaths in noneclamptics occurred in women of parity greater than or equal to 5. Similarly, most deaths from eclampsia occurred in women aged less than or equal to 24 years, while most in the noneclamptic group were aged 25 years and greater. The most common avoidable factors were patient-orientated problems-women who either presented late for antenatal care or late to hospital when symptomatic. Administrative factors also played a major role, in that there was a delay in referral due to the unavailability of transport. The lack of protocols of management or failure to follow clinical protocols of care contributed towards avoidable medical factors. Most women presented as an emergency event and failure of resuscitation/achievement of hemodynamic stabilization constituted a significant avoidable factor. Clear protocols for management of hypertension in pregnancy at all levels of health care are required.