SEVERE ACUTE MATERNAL MORBIDITY/NEAR MISS MATERNAL MORBIDITY

Sangeetagupta Seniorconsultant&HOD,

Deptt of Obst.&Gynae,ESIPGIMSR,Basaidarapur

I keep six honest serving men, I keep six honest serving men,

They taught me all I knew,They taught me all I knew,

Their names are What ,Why, WhenTheir names are What ,Why, When

, How ,Where and Who., How ,Where and Who.

Rudyard KiplingRudyard Kipling

MATERNAL MORTALITY IS “JUST THE TIP OF ICEBERG” HAS VAST

BASE TO THE ICEBERG—MATERNAL MORBIDITY-WHICH

REMAINS UNDESCRIBED

WHO

A maternal near-miss case “awoman 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

nearmiss cases when they survive life-threatening conditions (i.e. organd ysfunction).

A severe life-threatening obstetric complication necessitating an urgent medical intervention in order to prevent likely death of the mother.

Any pregnant or recently delivered woman, in whom immediate survival is threatened and who survives by chance or because of the hospital care she received.

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 ago. In low maternal mortality

settings

morbidity usefulindicator of obstetric care

in recent years analyzing near miss/SAMM cases

understanding health system failures in

relation to obstetric care

Near miss/SAMM 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-termmorbidity.

Why maternal near miss?

Near miss cases occur more often than maternal death and may generate more information because the woman herself can be a source of data.

Once severe maternal morbidity precedes maternal death, the systematic identification and the study of near miss cases may provide further understanding of the determinants of maternal mortality

is calling for improving maternal health

World wide.

5th MDG

MORBIDITY>>>MORTALITYTHE CONTINUUM

Normal PregnancyNormal Pregnancy

Clinical problem Clinical problem (Morbidity)(Morbidity)

Organ DysfunctionOrgan Dysfunction

Organ FailureOrgan Failure

DeathDeath

Near MissNear Miss

Mantel et alMantel et alBJOG 1998BJOG 1998

Normal Normal DeathDeath NearNear MissMiss

SevereSevere MorbidityMorbidity MorbidityMorbidity

UNDERSTANDING TRENDS IN MORBIDITY

Anticipate/ react to illnesses >>> reduce MMR

Identify common predictive factors >>> more effective preventative strategies

Normal Normal DeathDeath NearNear MissMiss

SevereSevere MorbidityMorbidity MorbidityMorbidity

~~HOW TO IDENTIFY CASES OF NEAR MISS

MATERNAL MORBIDITY~~

Severe acute morbidity/Complication

Severe maternal outcome

Near miss(narrowly escapes death)

Maternal death

WHO NEAR MISS APPROACH

Severe maternal complications are defined

as “potentially life-threatening conditions”. This

is an extensive category of clinical conditions,including diseases that can threaten a

woman’s lifeduring pregnancy ,labour and after terminationof pregnancy.

WHO NEAR MISS APPROACH

Severe maternal complications• Severe postpartum haemorrhage• Severe pre-eclampsia• Eclampsia• Sepsis or severe systemic infection• Ruptured uterus• Severe complications of abortion

WHO NEAR MISS APPROACH

• Admission to intensive care unit• Interventional radiology• Laparotomy(includes hysterectomy, excludes

caesarean section)• Use of blood products

WHO NEAR MISS APPROACHLife Threatening conditions

Cardiovascular dysfunction• Respiratory dysfunction• Renal dysfunction• Coagulation/haematological dysfunction• Hepatic dysfunction• Neurological dysfunction• Uterine dysfunction Uterine haemorrhage or infection leading to hysterectomy

Severe maternal outcome refers to a life-threatening condition (i.e. organ dysfunction),

\including all maternal deaths and maternal near-miss cases.

Women with life-threatening conditions (WLTC) refers to all women who either qualified as maternal near-miss cases or those who died (i.e. women presenting a severe maternal outcome). It is the sum of maternal near-miss and maternal deaths (WLTC = MNM + MD).

WHO systematic review of maternal morbidity and mortality: the prevalence of severe acute maternal morbidity (near miss)\

Prevalences

0.80% – 8.23% in studies that use---- disease-specific criteria

0.38% – 1.09% in the group that use ---organ-system based criteria and included unselected group of women.

0.01% and 2.99% in studies using management-based criteria.

In resource-poor settings, 4–8% of pregnant women who deliver in the hospitals will experience SAMM

This rate is around 1% when the organ failure is considered. In more developed country settings, the rates are around 1% with disease-

specific and 0.4% with organ-system based criteria, respectively. The results also suggest that the use of organ-system based criteria is more specific in identifying the real SAMM cases.

UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), published/unpublished data from 1997 to 2002.

Lale Say1*,

prevalence of SAMM is higher in studies conducted in less developed country settings

Obstetric HDU is highly specialised and discrete area

within the delivery suite/labour room for SAMM

WITH BEST FACILITY AND TEAM TO TREAT .

ADVANTAGES OF HDU

EARLY INTERVENTION AND SPECIALISED TREATMENT CAN PREVENT SERIOUS COMPLICATION AND AVOIDS HAZARDS OF TRANSFER OF PATIENT TO ICU IN SEPARATE LOCATION

ANTENATAL , INTRAPARTUM AND POST NATAL CARE CAN BE PROVIDED BY THE SAME TEAM

HDU MAY AVOID EXPOSURE OF CRITICALLY ILL PREGNANT PATIENTS TO HAZARDOUS ICU ENVIRONMENT WITH RISK OF HOSPITAL ACQUIRED INFECTIONS.

IT IS A NEED OF MOST TERTIARY CENTRES , High dependency care opposed to full

intensive care has a valid option in terms of efficacy and cost benefit

Conclusions

Reviewing cases of severe maternal morbidity can provide useful complimentary insights into quality of care.

A good quality medical system is required

Missing Mothers.avi