John Figgis Jewett

Endotoxin shock and the generalized Shwartzman reaction in pregnancy

Abstract The clinical and pathologic findings in 7 pregnant patients with endotoxin shock have been presented. Escherichia coli was the most common infective organism. The syndrome occurred in 2 clinical situations; namely, (1) infected abortion, and (2) premature rupture of the membranes with chorioamnionitis and placentitis. The presence of bilateral renal cortical necrosis due to disseminated intravascular coagulation in 3 of these patients demonstrates that the human being is subject to the generalized Shwartzman phenomenon. A comparison between the response of the patient and that of the experimental animal to intravenous bacterial endotoxin has been made. Both showed marked alterations in the blood coagulation mechanism associated with disseminated intravascular coagulation and both exhibited profound, sometimes irreversible, shock. Animal experiments suggest that the shock is caused by a decreased venous return to the right side of the heart because of obstruction of the portal circulation by the liver. The obstruction may be due to vasospasm and thrombosis of the central veins of the liver. Acute cor pulmonale may also contribute to the decreased cardiac output and hence to the systemic hypotension. A general discussion of the current armamentarium in the management of these cases has been presented.

Anesthetic-related maternal mortality, 1954 to 1985

This is a population-based study of the safety of obstetrical anesthesia in the Commonwealth of Massachusetts between 1954 and 1985. We used data collected by the state Committee on Maternal Mortality, which was founded in 1941. There were a total of 37 maternal deaths during the study period due to anesthetic-related complications. During the same time period, there were 886 maternal deaths. Thus, anesthetic-related mortality comprised 4.2% of all deaths, and the mortality rate was 1.5 per 100,000 live births between 1955 and 1964, 1.5 per 100,000 live births between 1965 and 1974, and 0.4 per 100,000 live births between 1975 and 1984. In the first decade of this study, aspiration during administration of a mask anesthetic was the primary cause of death. During the second decade, cardiovascular collapse associated with regional anesthesia was the primary cause of death. During the last decade of this study, all deaths were associated with general endotracheal anesthesia. As a result of this study and having identified the changes in the standard of care in Massachusetts that led to the reduction in maternal mortality, we offer recommendations to further improve the safety of anesthesia for childbirth in this country.

Reproductive Mortality in Massachusetts in 1981

This study analyzed reproductive deaths (all deaths from pregnancy-related causes, including abortion and ectopic pregnancy, as well as from causes related to contraception) among women 15-44 years of age in the state of Massachusetts in 1981. Of the 971 deaths recorded in this age group, 14 were classified as reproductive deaths, for an overall reproductive mortality rate of 1.8/10,000 live births (1/100,000 women). 10 of these deaths were pregnancy related, and 4 were due to pregnancy prevention (oral contraception). 4 of the pregnancy-related and 3 of the contraception-related deaths were considered preventable since they occurred in women in whom oral contraception (OC) had been contraindicated. The risks related to OC use were higher than those related to pregnancy for women over 35 years of age, suggesting that the reproductive mortality rate could be reduced by proscribing OC use in women in this age group, especially in women who smoke or have hypertension. It is concluded that the reproductive mortality rate is a better measure of the risk associated with reproduction that the maternal mortality rate, and it is recommended that committees on maternal mortality expand their surveillance to include deaths due to the side effects of contraception.

Maternal Mortality in the United States: Report from the Maternal Mortality Collaborative

To better define the incidence, causes, and risk factors associated with maternal deaths, the Maternal Mortality Collaborative in 1983 initiated national voluntary surveillance of maternal mortality. The Maternal Mortality Collaborative reported 601 maternal deaths from 19 reporting areas for 1980-1985, representing a maternal mortality ratio of 14.1 per 100,000 live births. Overall, 37% more maternal deaths were reported by the Maternal Mortality Collaborative than by the National Center for Health Statistics for these reporting areas. Older women and women of black and other races continued to have higher mortality than younger women and white women. The five most common causes of death for all reported cases were embolism, nonobstetric injuries, hypertensive disease of pregnancy, ectopic pregnancy, and obstetric hemorrhage. Compared with national maternal mortality for 1974-1978, ratios were lower for all causes except for indirect causes, anesthesia, and cerebrovascular accidents. Fatal injuries among pregnant women are not commonly reported to maternal mortality committees. As maternal mortality from direct obstetric causes continues to decline, clinicians will need to emphasize preventing deaths from nonobstetric causes.