maternal near miss at holy family hospital prof. fehmida shaheen head of obs/gynae unit-ii holy...
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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>>>MortalityMorbidity>>>MortalityThe ContinuumThe 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.
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.
Why Maternal Near Miss?
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 near-
miss approach for maternal health. Geneva: WHO, 2011”
WHO set of WHO set of Severity Markers Severity Markers used in maternal near miss assessmentsused in maternal near miss assessmentsGroup A* Group B*
Cardiovascular dysfunction 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 / Hematological dysfunction
Clotting failure Transfusion of ≥ 5 units of blood / red cells
Acute thrombocytopenia (<50 000 platelets)
Hepatic dysfunction Jaundice in the presence of Pre-eclampsia Billirubin> 100 mmol/l or 6,0 mg/dl
Neurological dysfunctions Metabolic coma (loss of consciousness AND the presence of glucose and ketoacids in urine)
Stroke Status epilepticus / Uncontrollable fits / total
paralysis
Coma / loss of consciousness lasting 12 hours or more
Urine dysfunction Hysterectomy due to infection or hemorrhage
*A glossary with relevant operational definitions “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”.
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, RawalpindiDuration 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
Age (years) 28.4 ± 4.75 S.D 27.8 ± 4.80 S.D
Parity
Primipara
Multipara
72 (36.36%)
126 (63.63%)
9 (18.3%)
40 (81.7%)
Gestational age (weeks)
1-12
13-28
>28
Postnatal
8 (4.04%)
17 (8.59%)
131 (66.66%)
41 (20.71%)
2 (4.08%)
5 (10.20%)
28 (57.14%
14 (28.57%)
Diagnosis Near miss MNM Per 1000 live births
Mortality Mortality index %
Hypertensive disorders of pregnancy Severe preeclampsia Eclampsia HELLP syndrome
96029202
6.09 13 11.92
Severe haemorrahge Early pregnancy
o Ectopic pregnancy o Abortion
Late pregnancy o Abruption o PPH o Placenta Previa / Accretao Ruptured Uterus
61
0301
10231806
3.87 19 23.75
Sepsis 8 0.51 6 42.86
Pulmonary Embolism 0 4 100
Cardiac 7 0.4 3 70
Anesthetic complications 4 0.25 1 20
Others 17 1.07 1 5.5
Indirect 5 0.32 2 28.57
Total 198 12.81 49 19.8
Comparison of near miss events and primary causes of maternal deaths
Surgical Intervention in Near Miss Cases to Save Life (n=89)
Surgical Interventions Cases
Peripartum Hysterectomies 37
Laparotomies
Rupture uterus
Internal iliac ligation
B lynch application
Ruptured ectopic
Pus in peritoneal cavity
Drainage of sub rectal haematoma
20
11
02
01
03
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 management of
maternal near miss cases (poor resources, inadequate utilization
of resources at tertiary level).
NEAR MISS ANALYSIS IS WORTH
PRESENTING IN NATIONAL INDICES.
MotherMother
Tragedies are
always in her path
and its our
responsibility to
give her a safe
motherhood
Thanks Thanks
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