SEVERE ACUTE MATERNAL MORBIDITY/NEAR MISS MATERNAL MORBIDITY Sangeetagupta Seniorconsultant&HOD, Deptt of Obst.&Gynae,ESIPGIMSR,Basaidarapur

I keep six honest serving men, They taught me all I knew, Their names are What,Why, When, How,Where and Who. Rudyard 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 “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 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 useful indicator 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-term morbidity. 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. 5 th MDG

M ORBIDITY >>>M ORTALITY T HE C ONTINUUM Normal Pregnancy Clinical problem (Morbidity) Organ Dysfunction Organ Failure Death Near Miss Mantel et al BJOG 1998 NormalDeath Near Miss Severe Morbidity Morbidity

U NDERSTANDING T RENDS IN M ORBIDITY Anticipate/ react to illnesses >>> reduce MMR Identify common predictive factors >>> more effective preventative strategies NormalDeath Near Miss Severe Morbidity Morbidity

~~H OW TO IDENTIFY CASES OF NEAR MISS MATERNAL MORBIDITY ~~

Severe acute morbidity/Complication Severe maternal outcome Near miss (narrowly escapes death) Maternal death

WHO N EAR M ISS A PPROACH 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 life during pregnancy,labour and after termination of pregnancy.

WHO N EAR M ISS A PPROACH Severe maternal complications Severe postpartum haemorrhage Severe pre-eclampsia Eclampsia Sepsis or severe systemic infection Ruptured uterus Severe complications of abortion

WHO N EAR M ISS A PPROACH Admission to intensive care unit Interventional radiology Laparotomy(includes hysterectomy, excludes caesarean section) Use of blood products

WHO N EAR M ISS A PPROACH Life 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 Lale Say1*,1

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