Transcript Mother

MATERNAL NEAR MISS AT HOLY
FAMILY HOSPITAL
Prof. Fehmida Shaheen
Head of Obs/Gynae Unit-II
Holy family Hospital, Rawalpindi
Maternal mortality is “Just the tip of iceberg”
has
vast base to the iceberg maternal
morbidity which remains undescribed.
Morbidity>>>Mortality
The Continuum
Definition of Maternal Near Miss
“A maternal near-miss case “a woman who nearly died
but survived a complication that occurred during pregnancy,
childbirth or within 42 days of termination of pregnancy”
In practical terms, “women are considered near miss
cases when they survive life-threatening conditions (i.e. organ
dysfunction)”.
A very ill woman who would have died had it not been
that luck and good care was on her side.
Why Maternal Near Miss?

Two decades age,
in low maternal mortality
setting, Morbidity useful indicator of obstetrics
care.

In recent years analyzing near miss cases
understanding health system failures in relation to
obstetrics care
Why Maternal Near Miss?

Near miss cases share many characteristics with
maternal deaths and can directly inform on
obstacles that had to be overcome after the onset
of an acute complication.

Corrective actions for identified problems can be
taken to reduce related mortality and long-term
morbidity.
Concept of Maternal Near Miss
For last 20 years it has been explored in maternal
health

As an adjunct to maternal death confidential
inquiries

Have been studied as surrogates of maternal deaths
The WHO Maternal Near Miss
Approach

A benchmark practice for monitoring maternal
health care

Criteria for diagnosis of maternal near miss has
been standardized
“WHO. Evaluating the quality of care for severe pregnancy complications: the WHO nearmiss approach for maternal health. Geneva: WHO, 2011”
WHO set of Severity Markers used in maternal near miss assessments
Cardiovascular dysfunction
Group A*
Group B*




Shock
Lactate >5


pH<7.1
Use of continuous vasoacitve
drugs
Cardiac arrest
Cardio-pulmonary resuscitation
(CPR)
Respiratory dysfunction



Acute cyanosis
Respiratory rate > 40 or < 6/min
Oxygen saturation < 90% for ≥ minutes



Gasping
PaO2/FiO2<20 mmHg
Intubation and ventilation not
related to anesthesia
Renal dysfunction
Oliguria non responsive to fluids or diuretics

Creatinine ≥ 300 mmol/l or ≥ 3,5
mg/dl
Dialysis for acute renal failure

Coagulation
dysfunction
/
Hematological 

Clotting failure
Transfusion of ≥ 5 units of blood / red cells
Hepatic dysfunction
Jaundice in the presence of Pre-eclampsia
Neurological dysfunctions



Urine dysfunction
Acute thrombocytopenia (<50 000
platelets)
Billirubin> 100 mmol/l or 6,0 mg/dl
Metabolic coma (loss of consciousness AND Coma / loss of consciousness lasting
the presence of glucose and ketoacids in 12 hours or more
urine)
Stroke
Status epilepticus / Uncontrollable fits / total
paralysis
Hysterectomy due to infection or hemorrhage
“World Health Organization. Evaluating the quality of care for severe pregnancy complications: the WHO
near-miss approach for maternal health. Geneva: World Health Organization, 2011”.
*A glossary with relevant operational definitions
Benefit of setting the criteria for
diagnosis of maternal near miss

Common ground for implementation of near miss
assessments across countries

Allows international comparisons to be carried out
Objective of Our Study
To determine the :
1.
Frequency
of
maternal
near
miss,
MNM
Incidence Ratio (MNMIR) and mortality index
2.
Analyze the nature of maternal near miss events
3.
To compare the causes of maternal near miss with
that of maternal mortality
Material and Methods
Place of study: Gynae Unit II Holy Family Hospital, Rawalpindi
Duration of Study: 1st Jan 2012 To 31st Oct 2013
Holy Family Hospital Provides

Antenatal care

Delivery services to both high and low risk
pregnant women

24hours emergency obstetric services

24hours blood bank facility

Blood
component
therapy
(available
during
morning hours only)

Surgical and medical intensive care units (ICUs)
Selection Criteria

Maternal near miss cases were selected which met WHO
2009 criteria (a set of clinical, laboratory and management
based criteria)

Maternal mortality during the study period was analyzed

Patient characteristics including age, parity, gestational age
at admission and surgical intervention to save the life of
mother were considered
Maternal near miss and maternal
mortality cases
All were categorized by final diagnosis with
respect to

Direct causes ( hypertension, hemorrhage, sepsis
etc.)

Indirect causes (anemia, cardiac disease etc.)
Maternal Near Miss Indices

MNM Incidence Ratio
(MNMIR = MNM/1000 live births)

Maternal near miss and mortality ratio
(MNM : MD)

Mortality index
([MD/MNM +MD]×100)
Results
Study Period: 1st Jan 2012 to 31st Oct 2013
Total live births
15,757
Total maternal near miss cases
198
Total maternal deaths
49
Characteristic of Maternal Near Miss
Cases and Maternal Deaths
Characteristics
Maternal Near miss, n= 198
Maternal deaths, n=49
28.4 ± 4.75 S.D
27.8 ± 4.80 S.D
Primipara
72
(36.36%)
9 (18.3%)
Multipara
126 (63.63%)
40 (81.7%)
1-12
8
(4.04%)
2
(4.08%)
13-28
17
(8.59%)
5
(10.20%)
>28
131 (66.66%)
28 (57.14%
Postnatal
41
14 (28.57%)
Age (years)
Parity
Gestational age (weeks)
(20.71%)
Comparison of near miss events and primary causes of maternal deaths
Diagnosis
Near miss
Mortality Mortality index %
MNM Per
1000 live births
Hypertensive disorders of pregnancy
 Severe preeclampsia
 Eclampsia
 HELLP syndrome
96
02
92
02
6.09
13
11.92
Severe haemorrahge
 Early pregnancy
o Ectopic pregnancy
o Abortion
 Late pregnancy
o Abruption
o PPH
o Placenta Previa / Accreta
o Ruptured Uterus
61
3.87
19
23.75
Sepsis
8
0.51
6
42.86
0.4
0.25
1.07
0.32
12.81
4
3
1
1
2
49
100
70
20
5.5
28.57
19.8
Pulmonary Embolism
Cardiac
Anesthetic complications
Others
Indirect
Total
03
01
10
23
18
06
0
7
4
17
5
198
Surgical Intervention in Near Miss Cases to
Save Life (n=89)
Surgical Interventions
Cases
Peripartum Hysterectomies
37
Laparotomies
20

Rupture uterus
11

Internal iliac ligation
02

B lynch application
01

Ruptured ectopic
03

Pus in peritoneal cavity

Drainage of sub rectal haematoma
02
01
WHO Criteria 2009
• Incorporates both mantel’s and waterston criteria
• Minimizes the chance of missing the case.
(M. Waterstone, C. Wolfe, and S. Bewley, “Incidence and pre-dictors of
severe obstetric morbidity: case-controlstudy,” British Medical Journal,
vol. 322, no. 7294, pp. 1089–1093, 2001.)
MNM incidence ratio in our study: 12.5/1000 live births
Comparable to studies in developing countries
Same trend vary between 15-40 / 1000 live births.
However
various criteria for identifying the cases were used.
(J. van Roosmalen and J. Zwart, “Severe acute maternal morbidity in
high-income countries,” Best Practice and Research: Clinical Obstetrics
and Gynaecology, vol. 23, no. 3, pp. 297–304, 2009).
Our MNMIR
12.5 / 1000 live births
Study from Brazil
4.4 / 1000 live births
(in an intensive care unit)
Study from India
17.8 / 1000 live birth
F. A. Lotufo, M. A. Parpinelli, S. M. Haddad, F. G. Surita, and J. G. Cecatti,
“Applying the new concept of maternal near-miss in an intensive care unit,”
Clinics, vol. 67, no. 3, pp. 225–230, 2012.
Roopa PS, Shailja Verma, Lavanya Rai, Pratap Kumar, Murlidhar V. Pai,
JyothiShetty. “Near Miss’’ Obstetric Events and Maternal Deaths in a Tertiary Care
Hospital: An Audit. Hindawi Publishing Corporation Journal of Pregnancy Volume
2013, Article ID 393758, 5 pages http://dx.doi.org/10.1155/2013/393758
Maternal Mortality Ratio
During the study period 310 / 100,000 live births
Indian study
313 / 100,000 live births
(Roopa PS, Shailja Verma, Lavanya Rai, Pratap Kumar, Murlidhar V. Pai,
JyothiShetty. “Near Miss’’ Obstetric Events and Maternal Deaths in a Tertiary Care
Hospital: An Audit. Hindawi Publishing Corporation Journal of Pregnancy Volume
2013, Article ID 393758, 5 pages http://dx.doi.org/10.1155/2013/393758)
Brazilian Study
51.6/100,000 live births
(for the institution)
(F. A. Lotufo, M. A. Parpinelli, S. M. Haddad, F. G. Surita, and J. G. Cecatti,
“Applying the new concept of maternal near-miss in an intensive care unit,” Clinics,
vol. 67, no. 3, pp. 225–230, 2012).
Determinants of Maternal Near Miss
and Maternal Mortality
Main Determinants
Maternal Near
Miss
1. Hypertensive disorders
2. Haemorrhage
Maternal
Mortality
1. Haemorrahge
2. Hypertensive disorders
Characteristics of Cases in Both Groups
• Non booked
• Late referral
• Multiple seizures before admission in cases of
eclampsia
Mortality Index (MI=[MD/MNM+MD]×100)
Condition
Mortality Index
Pulmonary Embolism
100%
Cardiac Disease
70%
Sepsis
42.8%
Severe Haemorrahge
23.7%
Hypertensive disorders
11.9%
Study from Brazil
Main determinant of Maternal Near Miss
• Hypertensive disorders but no death
(probably appropriate intervention in an adequate time frame)
“(F. A. Lotufo, M. A. Parpinelli, S. M. Haddad, F. G. Surita, and J. G. Cecatti,
“Applying the new concept of maternal near-miss in an intensive care unit,”
Clinics, vol. 67, no. 3, pp. 225–230, 2012).”
Sepsis
•
In our study
MNMIR 0.5 / 1000 live births
•
Developed countries
MNMIR 0.2 / 1000 live births
Maternal Near Miss To Mortality Ratio
MNM:MD
•
In our study
4 :1
•
Study from Nepal
7.2 : 1
•
Syrian study
60 : 1
•
High income countries
117-223 : 1
Limitations of Our Study
• Retrospective analysis
• In a single unit
However
• New WHO criteria applied for maternal near miss
cases
Conclusion
Maternal Near Miss Analysis Provide information
• About obstacles leading to maternal near miss
(inadequate care at primary level, failure to anticipate or diagnose the
problem leading to late referral).
• Inappropriate
or
inadequate
maternal near miss cases
management
of
(poor resources, inadequate
utilization of resources at tertiary level).
NEAR
MISS
ANALYSIS
IS
WORTH
PRESENTING IN NATIONAL INDICES.
Mother
Tragedies
are
always in her path
and
its
our
responsibility
give
her
motherhood
a
to
safe
Thanks