河北省2012年度孕产妇死亡评审结果分析

Analysis on maternal death review results in Hebei in 2012

目的:通过孕产妇死亡评审及时发现和掌握产科各个环节中存在的问题,有针对性地提出干预措施和管理办法,降低孕产妇死亡率。方法:根据《河北省孕产妇及5岁以下儿童死亡评审办法》和《"降消"项目孕产妇死亡评审规范》要求,对上报到省级的疑难病历筛选后依据世界卫生组织的"十二格表"法进行分析评审。结果:评审的8例孕产妇死亡病例中,3例为羊水栓塞,2例肺栓塞,1例为微血管病性溶血,1例为妊娠期急性脂肪肝,肝功能衰竭,产后大出血,1例为Hellp综合征、脑出血、脑疝;其中可避免死亡6例,占75.0%。结论:应进一步加强项目管理,提高孕产妇健康管理服务质量;加强培训,提高产科助产专业技术水平;严格掌握剖宫产指征,降低剖宫产术后并发症;加强各部门相互配合,支持母婴安全工程。

Objective： To put forward interventional measures and management methods targeting to the existing problems in every links of obstetric department found in maternal death review,reduce maternal mortality rate. Methods： The intractable cases were screened out from cases reported to the Provincial Maternal and Child Health Care Center. The reasons and factors were analyzed according to Twelve-law of World Health Organization. Results： Among 8 case of maternal death,3 cases were due to amniotic fluid embolization,2 cases were due to pulmonary embolization,1 case was due to hemolysis microvascular disease,1 case was due to acute fatty liver of pregnancy,liver failure,postpartum hemorrhage,and 1 case was due to HELLP syndrome,cerebral hemorrhage,cerebral hernia. Six case could be avoided,accounting for 75. 0%. Conclusion： The measures can be taken include： further strengthening the project management to improve the quality of maternal health care management,conducting technical training to improve the capability of treatment transfer and first aid for critical pregnant and lying- in women,strictly grasping the cesarean section indications to reduce the cesarean section complications,strengthening the cooperation of all departments and supporting maternal and child safety engineering.