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