Patient profile and treatment outcomes of (near-miss) obstetric patients and evaluation of maternal mortality: a tertiary center experience

Objective

Severe morbidities which might result in maternal mortality are evaluated in the category of near-miss obstetric patients. Diagnosis, assessment, and treatment outcomes of near-miss patients whose mortality can be prevented with optimal and timely intervention have been accepted as indicators of maternal health status, worldwide. In this paper we evaluated characteristics and management of these cases and the maternal mortality related with the near-miss obstetric morbidities.  

Methods

Among patients referred to our hospital between August 1, 2010, and October 1, 2011, file information of the cases whose the criteria complied with near-miss maternal morbidity were analyzed retrospectively Their demographic characteristics, and their data kept in the patient files of Departments of Obstetrics, and Gynecology, General Surgery, and also Intensive Care Units, and all mortality data of deceased cases were analyzed.

Results

During the study period 84 patients (3.8 %) referred with near-miss maternal morbidities. The most frequently encountered underlying etiology was severe preeclampsia and HELLP syndrome (79.8 %), followed by cases with postpartum bleeding (16.7%). Perinatal mortality rate in this near-miss population was found to be 11.9% (n=10). All patients required monitorization in the intensive care unit. Four patients died during the follow-up (4.7%).

Conclusion

The most frequently seen risk factors in near-miss patients are also predominant etiologies for maternal mortality. Timely recognition and intervention can prevent mortalities seen in majority of these patients.

Keywords

Maternal mortality, near-miss, obstetric morbidity, treatment

Introduction

Maternal mortality rates are globally accepted as the most important criteria of women’s health. Among targets of healthy life for the millenium reported by World Health Organization (WHO), all encompassing fight against maternal mortality and minimization of mortality rates are included.[1] Within this frame, patients with metabolic abnormalities and severely deteriorated surgical patients secondary to obstetric complications, have a distinct, and crucial importance. Some of these patients die, and those who had received sufficient, and timely medical-surgical care can be salvaged.
Patients who survived despite development of life-threatening obstetric complications during pregnancy and postpartum period up to 42nd day were defined as near-miss patients by WHO.[2] The most important causes of near-miss maternal morbidity are complications related to obstetric hemorrhages, and hypertensive diseases of pregnancy.[3] Another important issue is that the incidence of long-term morbidities such as renal failure, respiratory tract problems, and sudden death within a year is higher when compared with the population in general.[4,5] Especially, mortalities, and morbidities related to obstetric bleedings can be largely prevented with timely, and sufficient medical, and surgical care.
Healthcare politics targeting a decrease in maternal mortality rates in our country have gained momentum beginning from the year 2000. Widespread, and effective antenatal care, increased availability of facilities enabling rapid transfer of emergency patients, establishment of sound, and reliable data banks like National Maternal Mortality Study have all reportedly decreased maternal mortality rates from 49.2/100,000 in 1998 to 19.4/100,000 in 2008.[6,7] Presently, among countries with higher-moderate income rates which participated in World Health Organization, Turkey ranks at the bottom with minimal maternal death rates.[8] On the other hand, our nationwide medical literature data related to the patient profiles of complicated cases included in the newly coined near-miss category are lacking. In the present study, the characteristic features of near-miss obstetric patients who referred with acute complications to our clinics of reference university of the region, and results of our management modalities were presented, and this issue was discussed under the light of current literature information.

Methods

Our study was planned as a retrospective clinical investigation in compliance with the principles established by Helsinki Declaration pertaining to human experiments. Electronic records of the patients referred with near-miss obstetric complications to Inonu University Faculty of Medicine, Department of Obstetrics, and Gynecology, between August 1, 2010, and October 1, 2011 were analyzed. As study inclusion criteria, 5 main criteria required for the definition of ‘near-miss morbidly obstetric patient’ as determined by Flippi et al. were used:[9] (1) Shock, emergent hysterectomy, caogulopathy severe bleeding requiring transfusion of more than 2 liters of blood products; (2) Severe preeclampsia, eclampsia, and diagnosis of HELLP (hemolysis, increased liver enzymes, thrombocytemia) syndrome; (3) Patients with sepsis, shock, and associated morbidities (body temperature <36°C or >38°C or systolic blood pressure <90 mmHg, and heart rate >120 bpm; (4) Diagnosis of dystocia associated with uterine rupture or dehiscence; (5) Symptoms of serious anemia (hemoglobin <6 g/dl) without evidence of severe bleeding.
Information about obstetric and demographic characteristics such as age, parity, gravida, gestational age, mode of delivery, mean birth weights, neonatal outcomes, hemodynamic status, amount of transfusion, requirement for intensive care, duration of hospitalization, intraoperative complications, morbidity, and mortality of the patients operated on were recorded.
Data were analyzed using the Statistical Package for Social Sciences (SPSS) software (version 10.0 for Windows). All differences associated with a chance probability of .05 or less were considered statistically significant. Continuous variables are presented as mean±SD.

Results

During the study period of 15 months, 2,156 deliveries were performed in our clinics. Among them, 84 patients were cases with near-miss morbidities (3.8%). The most frequently seen underlying etiologies were severe preeclampsia, and HELLP syndrome (79.8%), followed by postpartum bleeding (16.7%). Distribution of patient diagnoses is presented in Table 1, and obstetric characteristics are shown in Table 2. Seventy-four (88.1%) patients had given birth by cesarean section. Twenty-four (35.5%) newborns required monitorization in the intensive care unit. At presentation intrauterine fetal death was detected in two patients. A 16-week pregnancy terminated in abortus. Eight newborns died in the neonatal intensive care unit because of complications related to extreme prematurity In conclusion, our perinatal mortality rate in near-miss patients was found to be 11.9% (n=10).
Operations performed on near-miss patients because of postpartum bleeding, and associated placental pathologies are presented in Table 3. Intra- and postoperative surgical complications were not seen in none of the patients operated for obstetric bleeding In our study, all patients required monitorization in the ICU. Mean blood loss (1,428 ml; range, 500-4,000 ml), mean amount of blood transfusion (4.3 U; range 1 to 17 U), and mean ICU stay (4 days; range 1 to 7 days) were also determined. Four out of 84 patients died (4.7%). One of these patients was referred to our clinics from another center with manifestations of hypovolemic shock, and consumption coagulopathy because of atonic bleeding. The patient underwent bilateral internal iliac artery ligation together with total hysterectomy. The patient who received a total of 17 units of blood transfusion died on the postoperative first day because of multiorgan failure, and disseminated intravascular coagulation. The second patient presented to emergency service with complaints of sudden dyspnea, and loss of conscious on postoperative 5th day, and died because of masive pulmonary embolism detected on emergent echocardiography. The third case was a multipar patient who was admitted to the ICU at her 16th gestational week with diagnoses of sepsis, and intrauterine ex fetus, and despite supportive treatment she died on postpartum 5th day because of multiorgan failure, and disseminated intravascular coagulation. The fourth patient developed HELLP syndrome with concomitant eclamptic seizures after childbirth in another medical center. She died on postpartum 10th day because of intracranial bleeding, cerebral edema, and cardiopulmonary arrest Diagnoses, demographic, and obstetric characteristics of deceased patients are presented in Table 4.

Discussion

Studies related to salvaged near-miss women during their pregnancies, childbirth, and postpartum periods have been considered as important indicators of obstetric care, and women’s health, worldwide. Our study is the first report about the inventory of near-miss obstetric patients in our country. In this study, as a clinics of obstetrics, and gynecology of our regional reference hospital, our incidence of near-miss mothers, and mortality rate related to this diagnosis were found to be 3.05%, and 4.7%, respectively. According to a recently reported review by WHO about maternal morbidity, and mortality, the prevalence of near-miss mothers ranges between 0.4, and 8 percent.[10] In reports from African countries its prevalence surprisingly climbs up to 25 percent.[9] This higher prevalence has been reportedly associated with uneven distribution of maternal care services among countries, and diversities among diagnostic criteria of ‘near-miss cases.
In 2009 WHO revised the diagnostic criteria of ‘near-miss patients’ to encompass disorders in each organ systems i.e. cardiovascular, respiratory, renal, hematologic, hepatic, and nervous systems.[2] On the other hand, some investigators reported that the frequency of overdiagnoses of near-miss patients will increase in case of usage of these criteria, and updated criteria have not been routinely used.[11,12] In our study, we used diagnostic criteria for near-miss patients recommended by Flippi et al. in 2005 instead of WHO criteria revised in 2009 because we have encountered difficulties in obtaining clinical, physiologic, and laboratory data of each organ system, and also these new criteria have not entered in routine clinical use.[5,9] In compliance with the literature, in our study hypertensive complications of pregnancy, and postpartum hemorrhages were the most (97.5%) frequently detected risk factors in near-miss patients. Thromboembolic complications which are the foremost etiologic factors of maternal mortality in developed countries were found only in our one patient who died because of cardiopulmonary arrest secondary to massive pulmonary embolism. Primary hepatic failure and sepsis are rarely seen etiologic factors which might eventually result in death of the patient (Table 1). A recent review by WHO on this issue have indicated that obstetric bleedings especially during postpartum period were predominant etiologic factors in maternal mortalities seen in African (33.9%), and Asian (30.8%) countries.[8] However, in Latin America hypertensive complications of pregnancy have been reported as the most frequently (25.7%) encountered causes of maternal mortalities.[8] The same review emphasizes that mortalities particularly due to pre-, and postpartum hemorrhages can be prevented, and reduction in maternal mortalities should be among the targeted priorities of the healthcare strategy. In our study, among 15 near-miss cases referred to us, and operated on for postpartum bleeding, only one patient died (success rate, 93.4%). In addition, any complication related to the intervention performed was not seen in our patients. We think that this higher success rate can be attributed to sufficient surgical experience gained by our staff about the management of serious postpartum bleeding, and most importantly to provision of rapid, and organized multidisciplinary intensive care facilities for near-miss patients in our university.
In the present study, the incidence of peripartum hysterectomy was found 0.32%. Similarly, in their 5-year retrospective study, Çetin et al. have reported a 0.29% incidence of peripartum hysterectomy in one of the major referral center (Department of Obstetrics and Gynecology, Cerrahpasa Medical Faculty, Istanbul University) of our country.[13]
Maternal mortality rate in the present study was 185/100,000. The other referral centers in eastern and south-eastern part of the country have reported surprisingly higher mortality rates. In their 4-year follow-up, Yalınkaya et al. have reported a 1,100/100,000 maternal mortality rate.[14] In their 3-year retrospective evaluation, Şahin et al. have also reported a maternal mortality rate of 960/100,000. The obstetric haemorrhages and hypertensive complications were noticed as pioneer causes of maternal mortality cases in both of the studies. The determinative factor for the survival of near-miss patients is the provision of timely and optimal medicosurgical care. A guideline published by WHO in 2005 formulated an algorithm for the management of near-miss patients.[16] The first step in this algorithm requires from countries to have a control on their national statistical data related to maternal mortalities, and near-miss patients. Although results we obtained in our study belong to a database of a single center, they are important in that they were retrieved from a data base of a regional reference hospital in consideration of guideline recommendations of WHO.

Conclusion

Near-miss obstetric patients are acute cases rapidly nearing to their deaths. These patients can be diagnosed based on accurate diagnostic criteria, and on a large scale they can be resuscitated with timely medicosurgical management. To achieve these targets, obstetric healthcare team should be equipped with adequate armamentarium, training, and experience, and also monitorization of the patients using a multidisciplinary approach including intensive care services should be ensured.. Implementation of nationwide healthcare policies related to the management of near-miss patients might considerably decrease maternal mortality.

References

1. World Health Organization, UNICEF, UNFPA and The World Bank.Trends in maternal mortality:1990 to 2008.Geneva: World HealthOrganization; 2010.
2. Say L, Souza JP, Pattinson RC; WHO working group on Maternal Mortality and Morbidity classifications. Maternal near miss - towards a standard tool for monitoring quality of maternal health care.  Best Pract Res Clin Obstet Gynaecol 2009;23:287-96.
3. WHO UN, UNFPA, the World Bank. Maternal mortality 2005. Estimates developed by WHO, UNICEF, UNFPA, and the World Bank. Geneva: World Health Organization; 2007.
4. Leung NY, Lau AC, Chan KK, Yan WW. Clinical characteristics and outcomes of obstetric patients admitted to the Intensive Care Unit: a 10-year retrospective review. Hong Kong Med J 2010;16:18-25.
5. Sousa MH, Cecatti JG, Hardy EE, Serruya SJ. Severe maternal morbidity (near miss) as a sentinel event of maternal death. An attempt to use routine data for surveillance. Reprod Health 2008;28:6.
6. T.C. Sağlik Bakanlığı Ana Çocuk Sağlığı ve Aile Planlaması Genel Müdürlüğü. Ulusal anne ölümleri çalışması. Ankara: Sağlık Bakanlığı; 2005.
7. Hacettepe Üniversitesi Nüfus Etütleri Enstitüsü (1999). Nüfus ve sağlık arastırması. Ankara: HÜNEE; 2008.
8. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet 2006;367(9516):1066-74.
9. Filippi V, Ronsmans C, Gohou V, Goufodji S, Lardi M, Sahel A, et al. Maternity wards or emergency obstetric rooms? Incidence of near-miss events in African hospitals. Acta Obstet Gynecol Scand 2005;84:11-16.
10. Say L, Pattinson RC, Gülmezoglu M. WHO systematic review of maternal morbidity and mortality: the prevalence of severe acute maternal morbidity\(near-miss). Reproductive Health 2004;1:1186.
11. Kaye DK, Kakaire O, Osinde MO. Systematic review of the magnitude and case fatality ratio for severe maternal morbidity in sub-Saharan Africa between 1995 and 2010. BMC Pregnancy Childbirth 2011:28;11:65.
12. Shrestha NS, Saha R, Karki C. Near miss maternal morbidity and maternal mortality at Kathmandu Medical College Teaching Hospital. Kathmandu Univ Med J (KUMJ) 2010;8:222-6.
13. Çetin O, Şen C, Çetin Dİ, Uludağ S, Aydoğan B, Erenel H. Acil peripartum histerektomi olgularının değerlendirilmesi: 5 Yıllık Deneyim. Perinatoloji Dergisi 2011;19:76 – 80.
14. Yalınkaya A, Özcan Y, Kaya Z, Savaş Z, Erdemoğlu M. Üniversite hastanemizde maternal mortalite onı. Perinatoloji Dergisi 2008;16:9-3.
15. Şahin HG, Kamacı M, Şahin HA, Şengül M, Çölçümen N. Van ve yöresinde maternal mortalite oranı ve etyolojide rol alan faktörlerin tespiti. Perinatoloji Dergisi 2001;9:252-5.
16. Pileggi C, Souza JP, Cecatti JG, Faúndes A. Neonatal near miss approach in the 2005 WHO Global Survey Brazil. J Pediatr (Rio J) 2010;86:21-6.

	File/Dsecription
	Table 1. The diagnosis of near miss obstetric cases.
	Table 2. Demographic and obstetric features of the near miss cases.
	Table 3. The associated placental abnormalities of the near miss cases and applied surgical interventions.
	Table 4. Obstetrical characteristics of the cases with maternal mortality.