The Black-White Disparity in Pregnancy-Related Mortality From 5 Conditions: Differences in Prevalence and Case-Fatality Rates

falseTucker, Myra J; Berg, Cynthia J

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; Callaghan, William M

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; Hsia, Jason. American Journal of Public Health97. 2 (Feb 2007): 247-51.

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We sought to determine whether differences in the prevalences of 5 specific pregnancy complications or differences in case fatality rates for those complications explained the disproportionate risk of pregnancy-related mortality for Black women compared with White women in the United States. We used national data sets to calculate prevalence and case-fatality rates among Black and White women for preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage for the years 1988 to 1999. Black women did not have significantly greater prevalence rates than White women. However, Black women with these conditions were 2 to 3 times more likely to die from them than were White women. Higher pregnancy-related mortality among Black women from preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage is largely attributable to higher case-fatality rates. Reductions in case-fatality rates may be made by defining more precisely the mechanisms that affect complication severity and risk of death, including complex interactions of biology and health services, and then applying this knowledge in designing interventions that improve pregnancy-related outcomes.

We sought to determine whether differences in the prevalences of 5 specific pregnancy complications or differences in case fatality rates for those complications explained the disproportionate risk of pregnancy-related mortality for Black women compared with White women in the United States. We used national data sets to calculate prevalence and case-fatality rates among Black and White women for preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage for the years 1988 to 1999. Black women did not have significantly greater prevalence rates than White women. However, Black women with these conditions were 2 to 3 times more likely to die from them than were White women. Higher pregnancy-related mortality among Black women from preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage is largely attributable to higher case-fatality rates. Reductions in case-fatality rates may be made by defining more precisely the mechanisms that affect complication severity and risk of death, including complex interactions of biology and health services, and then applying this knowledge in designing interventions that improve pregnancy-related outcomes.

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Headnote

Objectives. We sought to determine whether differences in the prevalences of 5 specific pregnancy complications or differences in case fatality rates for those complications explained the disproportionate risk of pregnancy-related mortality for Black women compared with White women in the United States.
Methods. We used national data sets to calculate prevalence and case-fatality rates among Black and White women for preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage for the years 1988 to 1999.
Results. Black women did not have significantly greater prevalence rates than White women. However, Black women with these conditions were 2 to 3 times more likely to die from them than were White women.
Conclusions. Higher pregnancy-related mortality among Black women from preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage is largely attributable to higher case-fatality rates. Reductions in case-fatality rates may be made by defining more precisely the mechanisms that affect complication severity and risk of death, including complex interactions of biology and health services, and then applying this knowledge in designing interventions that improve pregnancy-related outcomes.
(Am J Public Health. 2007; 97:247-251. doi:10.2105/AJPH.2005.072975)

For the past 5 decades, Black women have consistently experienced an almost 4-times greater risk of death from pregnancy complications man have White women. This increased risk of pregnancy-related death among Black women is independent of age, parity, or education.1,2 An increased risk of death from other conditions, such as breast and gynecological cancer, has also been reported for Black Women.3-5 Black women are also more likely to die from complications of pregnancy, including hemorrhage,6 hypertensive disorders of pregnancy,7 and cardiomyopathy.8 However, the reasons for this excess mortality remain unclear. Our lack of knowledge about what factors cause the disparity in pregnancy-related mortality between Black and White women impedes our ability to formulate appropriate research and to design interventions to eliminate this disparity.
Excess mortality from a condition can be caused by a higher prevalence of the condition, a higher case-fatality rate, or a combination of these factors. To better understand the reasons for the higher pregnancy-related mortality rate among Black women, we calculated prevalence and case-fatality rates for 5 selected complications of pregnancy among Black and White women to determine the contribution of each factor to the difference in pregnancy-related mortality ratios. These 5 conditions-preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage-account for 26% of all pregnancy-related deaths. We partitioned the Black-White gap in the pregnancy-related mortality ratio into 2 parts: 1 attributable to differences in prevalence and the other attributable to differences in case-fatality rates.

METHODS
The pregnancy-related mortality ratio (PRMR; deaths per live births) for a condition is the product of the prevalence rate of the condition (cases per live births) and the casefatality rate for the condition (deaths per cases). We calculated prevalence and case-fatality rates for preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage for Black and White women who died during 1988 to 1999. We selected these 5 conditions because they are potentially life threatening and because they were methodologically amenable to our analytic approach.
We defined the prevalence rate for each of the 5 selected conditions as the number of pregnant women with the condition per 100000 live births. We used data from the US National Hospital Discharge Survey (NHDS) to estimate the number of women with each selected pregnancy condition during the study period. We used the US National Vital Statistics System natality data to determine the number of live births over the same period.
Data for the NHDS are collected via an annual survey of hospital discharge records conducted by the National Center for Health Statistics and are used to calculate national statistics on inpatient hospitalizations. The NHDS uses a probability sample of nonfederal general and short-stay specialty hospitals and is representative of hospitalizations among the US civilian resident population.9 National natality data are also gathered by the National Center for Health Statistics and are actual counts of births compiled from birth certificates in the United States.10
We defined the case-fatality rate for each of the 5 selected conditions as the number of deaths attributable to that condition per 100 000 women with the condition. The numerators of the case-fatality rates were obtained from the Pregnancy Mortality Surveillance System (PMSS) at the US Centers for Disease Control and Prevention. The denominators were prevalence estimates we calculated using NHDS data.
The PMSS is an ongoing surveillance system of all pregnancy-related deaths in the United States.1 Pregnancy-related deaths are defined as deaths that occur during pregnancy or within 1 year after pregnancy has ended and that are caused by complications of the pregnancy, a chain of events initiated by the pregnancy, or the aggravation of an unrelated condition by the effects of the pregnancy. Because the PMSS uses multiple data sources, it identifies approximately one third more deaths caused by pregnancy complications than do surveillance systems that use death certificates alone.11
We defined the PRMR as the number of pregnancy-related deaths from each of the selected conditions per 100000 live births. The numerators for the PRMRs were pregnancyrelated deaths obtained from the PMSS. The denominators were live births from the US National Vital Statistics System natality files.
We first computed the prevalence and case-fatality rates for each pregnancy condition for both Black and White women; we then estimated the Black-White rate ratios, with 95% confidence intervals (CIs), for these 2 measures for each of the 5 selected conditions. For each condition, we partitioned the excess pregnancy-related mortality found for Black women into the percentage attributable to a greater prevalence rate and the percentage attributable to a higher casefatality rate.
To evaluate the statistical significance of our findings, we first calculated the standard errors for the prevalence and case-fatality rate estimates with relative standard error curves that were obtained by the regression of the variances of the totals on the estimates of the totals of selected variables.12 Then, to calculate CIs for the Black-White rate ratios for the prevalence and case-fatality rates, we used the Taylor linearization method.13 Because the PRMR is the product of the prevalence rate and the case-fatality rate, we determined the percentage contribution of each factor to the PRMR difference by converting the Black-White prevalence rate ratios, the Black-White case-fatality rate ratios, and the Black-White PRMRs to log base 10. We then partitioned the difference in the PRMRs for Black and White women into the sum of the difference in the prevalence and the difference in the case-fatality rates.
For delivery hospitalizations, the NHDS contains fields for up to 6 diagnoses in addition to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)14 VM code V27, which denotes delivery of a fetus of at least 20 weeks' gestation; the diagnoses are not necessarily ranked in order of clinical importance in the NHDS. Of records with at least 1 of the diagnoses of interest, 96% had only 1 of the diagnoses and the remaining 4% contained 2 to 4 diagnoses. For records that included more than 1 diagnosis, we used our knowledge of the progression of pathological processes in pregnancy to develop the following decision rules for selecting the condition judged most likely to be the cause of the death. If a code for placenta previa was present on the record, the case was classified as placenta previa regardless of other diagnoses. In the absence of a placenta previa code, eclampsia took precedence over preeclampsia. If a postpartum hemorrhage code existed along with eclampsia or preeclampsia, a case was classified as postpartum hemorrhage. On the other hand, if a postpartum hemorrhage code existed in combination with abruption, a case was classified as abruptio placentae. Eclampsia and preeclampsia were selected over abruptio placentae, because the former conditions were considered the likely etiology for abruption. If eclampsia or preeclampsia, abruption, and postpartum hemorrhage were all present, the case was considered attributable to eclampsia or preeclampsia.
Overall, 21.4% of the NHDS records used in our study did not include information on race, because since 1985 a significant proportion of the NHDS data have been obtained from administrative data sources that infrequently contain this information. A prior analysis demonstrated that in the NHDS, those hospitals whose data do not include race were in areas where the population was predominantly White; therefore, White individuals were underreported in the NHDS to a greater extent than were persons of other races.15 Thus, we designated records with unknown race as White. To determine the effect of an alternate method for allocating records with this variable missing, we also calculated prevalence and case-fatality rates after proportionally redistributing cases with unknown race according to the distribution of values among those for whom the race was known. We used the z test to determine whether the Black-White prevalence and case-fatality rate ratios obtained from the 2 methods of allocating cases with unknown race were significantly different statistically.
Fewer than 1% of the PMSS records lacked race information. For these deaths, the surveillance system assigned race according to the known distribution of race among other women who died of pregnancy-related causes in the same state and during the same year as the decedent

RESULTS
For the 5 pregnancy conditions that we selected, the Black-White prevalence rate ratios ranged from 0.8 for postpartum hemorrhage to 1.6 for eclampsia; none of these ratios statistically were significantly different from 1 (Table 1). However, case-fatality rates for all 5 conditions statistically were significantly higher among Black women. The casefatality rate ratios for Black versus White women ranged from 2.4 for placenta previa to 3.3 for postpartum hemorrhage.
For each of the selected complications, the PRMRs for Black women were between 2.5and 3.9-times greater than those for White women (Table 2). For each of the 5 conditions, at least two thirds of the difference in the Black-White PRMRs was attributable to higher case-fatality rates among Black women. One third or less of the difference was attributed to a higher prevalence of the condition among Black women, ranging from 0% for hemorrhage to 34% for eclampsia
The results were not significantly affected by the method used to redistribute women of unknown race. Ratios calculated after redistributing women with unknown race to White were not significantly different from those calculated when cases with unknown race were redistributed in proportion to the distribution of known cases (data not shown).
DISCUSSION
In 2000, the United States ranked 30th in maternal mortality in the world, and our poor international standing derives in part from racial disparities.16 We undertook this study to determine the relative contribution of 2 factors to the Black-White disparity in pregnancy-related mortality, neither of which had been previously examined. We used large, population-based databases to estimate prevalence and case-fatality rates for 5 pregnancy complications: preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage. The prevalence rates of these conditions among Black women were not significantly greater compared to those among White women. However, for all 5 complications, Black women had case-fatality rates that were 2- to 3-times greater than those of White women. This resulted in Black women having cause-specific PRMRs that were 2.5- to almost 4-times greater than PRMRs for White women.

Our decision to limit our analysis to the 5 selected pregnancy conditions (see box on this page) was dictated by 2 methodological issues: the need to account for the design of the NHDS and inconsistencies in coding that can occur in the ICD-9-CM.14
Our first consideration was that the NHDS data were organized by occurrence of hospitalization, not by individual being hospitalized, and if an individual had more than 1 hospitalization, no identifying data were available to link the separate hospitalizations, enabling the same person to be counted more than once. Traditionally, the pregnancy conditions that we selected for our analysis are almost always present during the delivery hospitalization, even if they also resulted in hospitalization prior to delivery. By limiting study cases to those present during the delivery hospitalization, we ensured that a woman who was hospitalized more than once with the same condition was only counted once-at the time of delivery.
The second consideration that led us to limit our analysis to the 5 selected conditions during the delivery hospitalization was that some complications that occur because of pregnancy can also occur in nonpregnant women. Although ICD-9-CM codes for pregnancy (630-676) should be used to code these conditions if they occur during pregnancy or the puerperium, sometimes the analogous code for the condition in the nonpregnant state is used. Limiting conditions to those that would be present during the delivery hospitalization made it less likely that we would miss complications that occurred before or after the delivery hospitalization but had not received the ICD-9-CM code indicating pregnancy.
The 5 pregnancy complications investigated accounted for a quarter of the pregnancy-related deaths reported to the PMSS during the study period.1 Other complications of pregnancy were not included, because either the NHDS does not contain a sufficient number of cases to provide a stable estimate for the study years (e.g., amniotic fluid embolism), the complications do not consistently manifest themselves during the delivery hospitalization (e.g., pulmonary embolism, cerebrovascular accident, and cardiomyopathy), or the complication may resolve and recur (e.g., infection). We elected to include postpartum hemorrhage because, although it may occur up to several weeks postpartum, 87% of cases occur within 24 hours of delivery,17 including most of those cases that are life threatening.18,19

The reporting of conditions and deaths could possibly differ by race. To calculate the prevalence rates, we used data from the NHDS. The Black-White prevalence rate ratios we estimated using NHDS data were similar to those obtained when using rates of complications for Black and White women derived from birth certificate data.20 To calculate the case-fatality rates, we used PMSS data1,21 to identify pregnancy-related deaths. A comparison of the PMSS data with maternal mortality data from the National Vital Statistics System did not reveal any difference between the 2 systems in their reporting of deaths from pregnancy complications for White and Black women.12 Although the prevalence and case-fatality rate estimates presented here may not be exact, our goal was the comparison of rates in White and Black women, and we have no reason to suspect that ascertainment of the selected conditions or deaths differed by race.
The fact that race was missing in 21 % of the records in the NHDS during the study period was problematic. In the NHDS, hospitals that do not report race have a larger proportion of White patients than do hospitals that report race.15 Consequently, we chose to designate women with unknown race as White. We believe this provides estimates close to the true population distribution. In addition, our analyses of the proportional reallocation of women with unknown race yielded results that did not differ significantly from those of our initial allocation method.
Several factors may contribute to the elevated case-fatality rates among Black women, including patient attributes, such as disease severity, coexisting medical conditions, and the timing of entry into care, and health system factors, such as access to care and the quality and consistency of care. Although researchers have increasingly accepted the idea that race is more of a social rather than a biological construct, race can have biological consequences, when operating through a variety of factors, that we were unable to measure in this study.22 Compared with White women, Black women are less likely to begin prenatal care in the first trimester and less likely to receive adequate care.23 Black women, including women of reproductive age, are more likely to have a comorbidity or preexisting medical condition, such as hypertension, diabetes, or obesity,24-27 which can affect the course of their pregnancy. In addition, a recent Institute of Medicine report found that for a wide variety of medical problems, minority patients receive a generally lower quality of care, even with equal access to care and insurance coverage.28
Because the number of pregnancy-related deaths is relatively small, national data sets were necessary to obtain sufficient numbers of cases for the analyses presented here. However, these national data sets did not allow us to examine the reasons for the disparity in case-fatality rates. After stratifying the deaths by condition and race, we lacked sufficient numbers to assess modifying factors such as age, region, and urban or rural residence.
To understand why Black women have higher case-fatality rates for the pregnancyrelated conditions we examined, a complex interaction of biological and health services factors must be untangled. We hope that research will advance beyond the descriptive epidemiology of racial disparities in pregnancy-related mortality to studies that will help elucidate the causes of disparity. Progress will depend on researchers' abilities to define more precisely the mechanisms affecting complication severity and risk of death and then to apply this knowledge in designing interventions that improve pregnancy-related outcomes.

 

Sidebar

International Classification of Diseases, Ninth Revision, Clinical Modification16 codes for 5 selected complications of pregnancy
Preeclampsia (642.4,642.5)
Eclampsia (642.6, 642.7)
Abruptio placentae (641.2)
Placenta previa (641.0, 641.1)
Postpartum hemorrhage (666.0-666.2)

 

References

 

1. Berg CJ, Chang J, Callaghan WM, Whitehead S. Pregnancy-related mortality in the United States, 1991-1997. Obstet Gynecol 2003;101:289-296.
2. Centers for Disease Control and Prevention. Differences in maternal mortality among Black and White women-United States, 1990. MMWR Morb Mortal Wkly Rep. 1995;44:6-7, 13-14.
3. Eley JW, Hill HA, Chen VW, et al. Racial differences in survival from breast cancer. Results of the National Cancer Institute Black/White Cancer Survival Study. JAMA. 1994;272:947-954.
4. Morgan MA, Behbekht K, Benjamen I, Berlin M, King SA, Rubin SC. Racial differences in survival from gynecologic cancer. Obstet Gynecol. 1996;88:914-918.
5. Hill HA, Eley JW, Harlan LC, Greenberg RS, Barrett RJ, Chen VW Racial differences in endometrial cancer survival: the Black/White Cancer Survival Study. Obstet Gynecol. 1996;88:919-926.
6. Chichakli LO, Atrash HK, Mackay AP, Musani AS, Berg CJ. Pregnancy-related mortality in the United States due to hemorrhage: 1979-1992. Obstet Gynecol. 1999;94:721-725.
7. Macay AP, Berg CJ, Atrash HK. Pregnancy-related mortality from preeclampsia and eclampsia. Obstet Gynecol. 2001;97:533-538.
8. Whitehead SJ, Berg CJ Chang J. Pregnancy-related mortality due to cardiomyopathy: United States, 1991-1997. Obstet Gynecol. 2003;102:1326-1331.
9. National Center for Health Statistics. National Hospital Discharge Survey multi-year datafile, 1979-99. Appendix B: Public-use data file and documentation. CD-ROM series 13 #19-A. May 2001.
10. National Center for Health Statistics. Natality data, public use data files, detail files 1988-1999. Available at: http://www.cdc.gov/nchs/products/catalog/subjects/ natality/htm.
11. MacKay AM, Berg CJ, Duran C, Chang J, Rosenberg H. An assessment of mortality from pregnancy in the United States. Fed Perinat Epidemiol. 2005;19:206-214.
12. National Center for Health Statistics. National Hospital Discharge Survey multi-year datafile, 1979-99. Public use data file and documentation. [CD-ROM series 13 No. 19-AJ May 2001.
13. Woodruff RS. A simple method for approximating the variance of a complicated estimate. J Am Stat Assoc. 1971;66:411-414.
14. National Center for Health Statistics. International Classification of Diseases, Ninth Revision, Clinical Modification. 4th ed. Washington, DC: US Government Printing Office; 1996.
15. Kozak LJ. Underreporting of Race in the National Hospital Discharge Survey. Hyattsville, Md: National Center for Health Statistics; 1995. Advance data from Vital and Health Statistics. No. 265.
16. World Health Organization. Maternal Mortality in 2000: Estimates Developed by WHO, Unicef and UNFPA. Geneva: WHO; 2003.
17. Hoveyda F, MacKenzie IZ. secondary postpartum hemorrhage: incidence, morbidity, and current management Brit J Obstet Gynecol. 2001;108:927-930.
18. American College of Obstetricians and Gynecologists. Postpartum hemorrhage. Washington, DC: ACOG; 1998. ACOG Educational Bulletin No. 243.
19. Rathore SS. McMahon MJ. Racial variation in the frequency of intrapartum hemorrhage. Obstet Gynecol. 2001;97:178-183.
20. Martin JA, Hamilton BE, Ventura SJ, Menacker F, Park MM Births: final data for 2000. Natl Vital Stat Rep. 2002;50:1-101.
21. Berg CJ, Atrash HK, Koonin LM, Tucker MJ. Pregnancy-related mortality in the United States, 1987-1990. Obstet Gynecol 1996;88:161-167.
22. Freeman HP. The meaning of race in science-considerations for cancer research. Cancer. 1998:82: 219-225.
23. Alexander GR, Kogan MD, Nabukera S. Racial differences in prenatal care use in the United States: are disparities decreasing? AmJ Public Health. 2002; 92:1970-1975.
24. Samedi AR, Mayberry RM, Zaidi AA, Pleasant JC, McGhee N, Rice RJ. Maternal hypertension and associated pregnancy complications among African-American and other women in the United States. Obslet Gynecol. 1996;87:557-563.
25. Geronimus AT, Andersen HF, Bound J. Differences in hypertension prevalence among US Black and White women of childbearing age. Public Health Rep. 1991;106:393-399.
26. Carter JS, Pugh JA, Monterrosa A. Non-insulindependent diabetes mellitus in minorities in the United States. Ann Intern Med. 1996:125:221-232.
27. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Trends and prevalence in obesity among US adults, 1999-2000. JAMA 2002;288:1723-1727.
28. Smedley BD, So'th AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press; 2002.

AuthorAffiliation

Myra J. Tucker, BSN, MPH, Cynthia J. Berg, MD, MPH, William M. Callaghan, MD, MPH, and Jason Hsia, PhD

AuthorAffiliation

About the Authors
The authors are with the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Ga.
Requests for reprints should be sent to Myra Tucker, Centers for Disease Control and Prevention, 4770 Buford Highway, NE (Mail Stop 23), Atlanta, GA 30341-3724.
This article ieas accepted February 23, 2006.
Contributors
M.J. Tucker and C.J. Berg designed and implemented the study. MJ. Tucker was primarily responsible for preparing the article, with substantial contributions from CJ. Berg and W. Callaghan. J. Hsia provided analytic expertise and statistical oversight All authors helped develop study ideas, interpret findings, and review drafts.
Acknowledgments
The authors gratefully acknowledge Lisa Flowers for data management and analytic support
Human Participant Protection
No human participation protocol approval was required for this study.

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4. Klik "Select a photo from your computer" untuk meng-upload foto profil Anda. Disarankan untuk menggunakan ukuran foto kecil saja dan persegi empat. Ini untuk memudahkan peng-upload-an dan pengaturan selanjutnya.
   
   
5. Setelah foto ter-upload, kita masih bisa mengatur gambar. Namun jika sudah sesuai dengan yang kita inginkan, klik "Set a Profile Photo".
   
   
6. Inilah tampilan foto profil akun email di gmail Anda. Pada tahap ini Anda masih diberi kesempatan untuk mengedit kembali foto profil jika belum sesuai seperti yang diinginkan. Jika sudah, klik "Next Step".
   
   
7. Selesai sudah semua tahap cara membuat email di gmail. Dan dari semua tahap tersebut, Anda sudah mendapatkan alamat email di gmail yang sudah bisa dibagikan kepada teman-teman, yaitu andreanwildan@gmail.com.
   
   
   Dengan mengikuti semua langkah cara membuat email di gmail ini, Anda juga sudah otomatis memiliki akun dan profil Google Plus (G+) yang merupakan satu-satunya profil pengguna semua layanan google lainnya.
   
   
Untuk melihat tampilan isi email di gmail anda, silahkan klik "Continue to Gmail".
8. Jika ada tampilan berikut, klik "Continue to the new look"
   
   
9. Dan inilah tampilan isi email di gmail Anda. klik Gambar untuk memperbesar (ukuran penuh).

                                              
 

Cara membuat blog di blogger 

Sebelum memulai, anda diharuskan untuk membuat akun GMAIL. Silahkan lihat Cara membuat email di gmail terlebuh dahulu.

Setelah email jadi, ikuti langkah langkah dibawah ini :

1. Silahkan kunjungi situs http://www.blogger.com
2. Setelah halaman pendaftaran terbuka, alihkan perhatian ke sebelah kanan bawah, ubah bahasa ke Indonesia agar lebih mudah difahami.
   
3. Silahkan langsung masuk/login dengan menggunakan username/nama pengguna serta password/sandi gmail anda ( akun email anda bisa untuk login ke blogger).
   
   
   
   
4. Isilah formulir yang ada :
   1. Nama tampilan : isi dengan nama yang ingin tampil pada profile blog anda.
   2. Jenis Kelamin : pilih sesuai dengan jenis kelamin anda, misal : pria.
   3. Penerimaan Persyaratan : Beri tada ceklis sebagai tanda anda setuju dengan peraturan yangtelah di tetapkan oleh pihak blogger. Saran: sebaiknya anda membaca terlebih dahulu persyaratan yang ada agar anda tahu dan mengerti apa yang boleh dan tidak diperbolehkan ketika menggunakan layanan blogger.
   4. Klik tanda panah bertuliskan “Lanjutkan”.
      
      
5. Klik tombol “Blog Baru”.
   
   
   
   
6. Isilah formulir :
   1. Judul : Isi dengan judul blog yang di inginkan, misal : Coretan sang penghayal
   2. Alamat : isi dengan alamat blog yang di inginkan. Ingat! Alamat ini tidak dapat di edit kembali setelah dibuat, apabila anda ingin serius, maka pilihlah nama yang benar-benar anda inginkan.
   3. Template : pilih template (tampilan blog) yang disukai (ini dapat ganti kembali).
   4. Lanjutkan dengan klik tombol “Buat blog!”.
      
      
      
      
   5. Sampai disini blog anda telah berhasil di buat.
7. Untuk menghindari spam filter, sebaiknya anda langsung posting sembarang saja. Klik tulisan “Mulai mengeposkan”.
   
   
   
   
8. Isi judul serta artikel. Akhiri dengan klik tombol “Publikasikan”.
   
   
   
   
9. Silahkan lihat blog anda dengan klik tombol “Lihat Blog”
10. Selesai.

KEHAMILAN DENGAN LETAK SUNGSANG 

Letak Sungsang

      A.    Pengertian

Letak sungsang adalah letak memanjang (Membujur) dalam rahim, kepala berada di fundus dan bokong di bawah.

      B.     Klasifikasi

      1.      Letak bokong murni => presentasi bokong murni (Frank Brech)

Bokong saja yang menjadi bagian depan sedangkan kedua tungkai lurus ke atas.

      2.      Letak bokong kaki =>Presentasi bokong kaki ( Complete Brech) disebut bokong teraba kedua kaki atau satu kaki saja.

      3.      Letak sungsang tidak sempurna (Incomplete Brech)

Adalah letak sungsang dimana selain bokong bagian yang terendah juga kaki atau lutut,

terdiri dari:

•      Kedua kaki : Letak kaki sempurna ( 24%)
•   Satu kaki : Letak kaki tidak sempurna (presentasi kaki)
•    Kedua lutut : Letak lutut sempurna (1%)
•  Satu lutut : Letak lutut tidak sempurna

Posisi bokong ditentukan oleh sakrum, ada 4 posisi :

1.      Left sacrum anterior (Sakrum kiri depan)
2.     Right sacrum anterior (Sakrum kanan depan)
3.      Left sacrum posterior (Sakrum kiri belakang)
4.       Right sacrum postrerior (Sakrum kanan belakang)

      C.    Etiologi

•    Fiksasi kepala pada pintu atas panggul tidak baik atau tidak ada, misalnya pada panggul sempit, hidrosefalus, anensefali, plasenta previa, tumor – tumor pelvis dan lain-lain.
•    Janin mudah bergerak, seperti pada hidramnion, multipara, janin kecil (prematur)
•   Gemelli (kehamilan ganda)
•    Kelainan uterus seperti uterus arkuatus, bikornis, mioma uteri
•     Janin yang sudah lama mati
•     Sebab yang tidak diketahui

      D.    Diagnosis

      1.      Pergerakan janin

Teraba oleh Ibu dibagian perut bawah, dibawah pusat dan Ibu sering merasa benda keras (kepala) mendesak tulang iga.

      2.      Palpasi

Teraba bagian keras, bundar dan melenting pada fundus. Kepala teraba di fundus, bokong dibagian bawah dan punggung di kiri atau kanan.

      3.       Auskultasi

Denyut jantung janin paling jelas terdengar pada tempat yang lebih tinggi dari pusat.

      4.      Pemeriksaan dalam

Dapat diraba tulang sakrum, tuber ischii dan anus, kaang – kadang kaki (pada letak kaki).

      5.      Pemeriksaan foto rontgen

Bayangan kepala di fundus.

      E.     Prognosis

Ø Bagi Ibu

Kemungkinan robekan pada perineum lebih besar, juga karena dilakukan tindakan, selain itu ketuban lebih cepat pecah dan partus lebih lama, jadi mudah terkena infeksi.

Ø  Bagi janin

Prognosa tidak begitu baik, karena adanya perdarahan darah plasenta setelah bokong lahir dan juga setelah perut janin lahir, tali pusat terjepit antara kepala dan panggul, anak bisa menderita asfiksia.

Oleh karena itu, setelah pusat lahir dan supaya janin hidup, janin harus dilahirkan dalam waktu 8 menit.

      F.     Pimpinan persalinan

Pertolongan persalinan dengan letak sungsang dapat dilakukan dengan :

•       Pertolongan pada kelahiran spontan
•        Ekstraksi parsiil atau manual aid
•        Ekstraksi
•       Secsio Sesaria

      G.    Mekanisme persalinan

Mekanisme persalinan sungsang hampir sama dengan letak kepala, hanya disini yang memasuki pintu atas panggul adalah bokong. Persalinan berlangsung agak lama, karena bokong dibandingkan dengan kepala lebih lembek, jadi kurang kuat menekan sehingga pembukaan agak lama.

Bokong masuk pintu atas panggul dengan garis pangkal paha melintang atau miring dengan turunnya bokong.Terjadi putaran sehingga didasar panggul garis pangkal paha letaknya menjadi muka belakang dengan trochanter depan sebagai hypomoclion (dibawah simpisis) terjadi latero fleksi tubuh janin (punggung) sehinggga trochanter belakang melewati perineum.Setelah bokong lahir diikuti kedua kaki kemudian teradi sedikit rotasi luar untuk memungkinkan bahu  masukpintun atas panggul dalam posisi melintang.Setelah bahu turun terjadi putaran paksi dari bahu sampai ukuran bisa cranial dalam ukuran muka belakang dari pintu bawah panggul karena itu punggung berputar lagi kesamping.

Pada saat bahu akan lahir kepala dalam keadaan fleksi masuk dalam ukuran pintu atas panggul.

Kepala ini mengadakan putaran paksi sedemikian rupa hingga kuduk terdapat di bawah sympisis da dagu sebelah belakang.

Berturut-turut lahir pada perineum dagu,mulut,hidung,dahi, dan belakang kepala.

Pertolongan dengan kelahiran spontan letak bokong murni

Biasanya ditolong secara Bracht.Pada primi gravida selalu didahului dengan episiotomi.Pada pertolongan secara bracht bokong diangkat keatas supaya badan janin searah dengan paksi jalan lahir, tidak dilakukan tarikan.

Tekhnik :

Pertolongan dimulai setelah bokong anak lahir.Pada letak bokong ini dipegang dengan dua tangan sedemikian rupa hingga kedua ibu jari pada permukaan belakang pangkal paha dan empat jari lainnya pada permukaan bokong.

Jika kaki sudah lahir seperti pada letak bokong kaki, letak lutut, letak kaki maka bokong dipegang sedemikian rupa sehingga ibu jariterletak pada lipat paha dan jari lainnya menggenggam bokong.

Bokong ini terus di bawa ke atas ke arah perut ibu sampai kepala lahir, keuntungan pertolongan dari cara Bracht ialah bahwa tangan sama sekali tidak masuk ke dalam jalan lahir, yang mengecilkan kemungkinan infeksi jalan lahir.

Jika persalinan dari cara Bracht mengalami kegagalan, misalnya bila terajadi kemacetan baik pada saat melahirkan bahu atau kepala maka pertolongan dilakukan secara manual aid (parcial breech extantion).

Tahapan prosedur manual  :

Ø  Tahap pertama : lahirnya bokong sampai pusat yang dilahirkan dengan kekuatan tenaga ibu sendiri

Ø  Tahap kedua :

·         Klasik

·          Mueller

·         Lovset

·           Bickenbach

            Ø   Tahap ketiga (lahirnya kepala) :

·        Mauriceau

·        Najouks

·        Wigan Martin, winclel

·         Prageu terbalik

·            Cunam piper

      H.    Penyulit

1.      Sufokasi : terjadi karena sebagian besar badan janin sudah lahir, terjadilah pengecilan rahim sehingga terjadi gangguan sirkulasi plasenta dan menimbulkan anoksia janin, keadaan ini merangsang janin untuk bernafas.Akibatnya darah, mukus, cairan amnion dan mekonium akan di aspirasi yang dapat menimbulkan sufokasi.

2.      Afiksia fetalis : selain akibat mengecilnya uterus pada waktu badan janin lahir yang menimbulkan anoksia dan di[perberat lagi dengan terjepitnya tali pusat pada waktu kepala masuk panggul.

3.      Kerusakan jaringan otak

4.      Fraktur pada tulang-tulang janin

      I.       Prosedur persalinan sungsang per abdominal

1.      Persalinan letak sungsang dengan sectio caesaria sudah tentu merupakan cara tebaik ditinjau dari keselamatan janin.

2.      Bahwa persalinan dengan letak sungsang harus dilahirkan per abdominal :

•        Primigravida tua
•         Nilai sosial janin tinggi
•          Riwayat persalinan yang buru
•          Janin besar >3,5 kg
•          Dicurigai adanya kesempitan panggul