Abstract: Objective to study the cause and risk fact leading to maternal death of pregnant woman due to illegal medical practice, discuss appropriate ways to avoid the death. Method we reviewed 11 cases related to maternal death referred for autopsy to our department from 2001-2005, all the decedents listed here were analyzed as to maternal pregnant condition, medical intervention and the cause of death. Results the most common cause of pregnancy related maternal death in our study were postpartum hemorrhage (PPH), amniotic fluid embolism (AFE), laceration of birth canal; the mostly encountered risk facts leading to the death in our study were lacking necessary antenatal care, delivering in a poor situation (mostly without qualified physicians and midwives, lacking emergency rescue service), being treated with oxytocin inappropriately or other destructive operation to facilitate delivery.

Key words: illegal medical practice, pregnancy woman, delivery, postpartum hemorrhage, amniotic fluid embolism

摘要： 目的研究上海地区非法行医致孕妇死亡案例并分析其特点,探究其形成原因及预防机制。方法收集本研究所2001～2005年接受上海市公安机关委托非法行医致孕妇死亡案例11例,按照孕妇情况、死亡原因及非法行医者的诊疗措施等进行分类整理分析。结果非法行医致孕妇死亡的原因多为产后大出血、羊水栓塞,多伴软产道裂伤。孕妇多未进行正规产前检查,到缺乏必要医疗条件的个体非法行医者处或者家中分娩,非法行医者往往存在不正当应用催产素,强行分娩,未采取及时有效抢救措施。

关键词: 非法行医, 孕妇, 分娩, 产后出血, 羊水栓塞