A Dissertation on

MATERNAL NEAR MISS MORBIDITY-AN

ANALYSIS OF 50 CASES

Dissertation submitted to
THE TAMIL NADU Dr.M.G.R.MEDICAL UNIVERSITY
CHENNAI.

in partial fulfilment of the regulations

for the Award of the degree of
M.S., (Obstetrics & Gynaecology)
Branch – II

INSTITUTE OF SOCIAL OBSTETRICS AND

GOVT. KASTURBA GANDHI HOSPITAL FOR
WOMEN AND CHILDREN
MADRAS MEDICAL COLLEGE
CHENNAI.
APRIL 2014
 BONAFIDE CERTIFICATE

Certified that this dissertation is the bonafide work of

Dr. M.PARAMESWARI on “MATERNAL NEAR MISS MORBIDITY –AN
ANALYSIS OF 50 CASES” during her M.S., (Obstetrics & Gynaecology)
course from April 2011 to April 2014 at the Institute of Social
Obstetrics, Government Kasturba Gandhi Hospital for Women and
Children, Madras Medical College, Chennai.

Prof.Dr.Ramani Rajendran Prof.Dr.S. DILSHATH,M.D.,D.G.O.,

M.D., D.G.O. Director
Professor & Chief of the Department ISO-KGH
Dept. of Obstetrics & Gynaecology, Madras Medical College,
ISO-KGH Chennai.
Madras Medical College
Chennai.

Prof. Dr. V. KANAGASABAI, M.D.,

DEAN,
Madras Medical College &
Rajiv Gandhi Government General Hospital,
Chennai.

Place :

Date :
 DECLARATION

I solemnly declare that the dissertation titled “MATERNAL

NEAR MISS MORBIDITY –AN ANALYSIS OF 50 CASES” is

done by me at INSTITUTE OF SOCIAL OBSTETRICS AND

GOVT. KASTURBA GANDHI HOSPITAL FOR

WOMEN AND CHILDREN, Madras Medical College under the

guidance and supervision of Prof. Dr.RAMANI RAJENDRAN M.D.,

D.G.O., Professor of Obstetrics and Gynaecology, Madras Medical

College, Chennai.

This dissertation is submitted to the Tamilnadu Dr. M.G.R

Medical University towards the partial fulfillment of requirements for

the award of M.S. Degree (Branch II) in Obstetrics and Gynaecology.

Place : Chennai

Date : Dr.M.Parameswari
 ACKNOWLEDGEMENT

I Thank Dr. V. Kanagasabai, M.D., Dean Madras Medical

College for permitting me to conduct this study in Institute of Social

Obstetrics and Government Kasturba Gandhi Hospital for Women and

Children, Chennai.

I owe my sincere thanks to Prof. Dr.S. Dilshath, M.D. D.G.O.

Director, ISO – KGH for her valuable guidance, during the study.

I express my profound gratitude to my guide Prof.Dr.Ramani

Rajendran, M.D. D.G.O., Professor of Obstetrics and Gynecology for

her unwavering support and encouragement.

My gratitude to my Assistant Professors, Statistician Mr.Ravanan

my colleagues and Hospital Staff and patients for enabling me to

complete the study.

 ABSTRACT

AIMS AND OBJECTIVES: To analyse , in a local context, the

incidence of MNMM,ADVERSE EVENTS and DISORDERS underlying

MNMM (as per WHO criteria),sociodemographic variables, contributing

factors and patterns of near miss situations and maternal deaths.

DESIGN: Facility- based observational study

STUDY POPULATION: All women with MNMM as identified by

WHO comprehensive criteria.(2009)

MAIN OUTCOME MEASURES:MNMM incidence ratio, Mortality

index

RESULTS: In the KGH study, 76% of MNMM were in late pregnancy (> 28

weeks),90% of MNMM patients were educated;52% of MNMM were

multigravida while 34% were primigavida; 64% came directly to the hospital;

32% had one referral between health facilities; and 4% had two referrals

between health facilities. 66% were near miss at the time of arrival; majority of

this group had Hypertensive disorders of pregnancy as the adverse event; 34.%

became near miss after admission to hospital. The most common adverse event

in this group of patients was Hemorrhage. The Cesarean Section Rate In KGH

was 52.52% Of All Hospital Deliveries while the Cesarean Section Rate Among
Near Miss Women Delivering At KGH Was 88%Multiparity, anemia ,diabetes

and previous caesarean section seem to be risk factors for developing MNMM.

Hypertensive disorders of pregnancy(52%) , Major obstetric Hemorrhage(42%)

and Cardiac causes (6%) were the common causes.

CONCLUSION: The MNMM INCIDENCE RATIO in this study is 0.8 per

1000 live births.This is comparable to High income developed countries where

it is between 0.6 and 1%.The Mortality Index is low;at 0.05,it reflects good

quality of care.The causes of Near Miss reflect the causes of maternal death.

Near miss analysis is worth presenting in national indices as a surrogate for

maternal death

KEY WORDS: Maternal near miss morbidity,hypertensive disorders of

pregnancy,obstetric hemorrhage,maternal near miss morbidity incidence ratio

 CONTENTS

S.No. TOPICS Page No.

1. INTRODUCTION 01

2. AIMS AND OBJECTIVES OF THE STUDY 03

REVIEW OF LITERATURE AND 04

3.
HISTORICAL BACKGROUND

4. MATERIALS AND METHODS 11

5 OBSERVATIONS AND RESULTS 20

6. DISCUSSION 63

7 SUMMARY AND CONCLUSIONS 82

8 BIBLIOGRAPHY 83

9. ANNEXURES
ABBREVIATIONS

WHO COMPREHENSIVE CRITERIA

PROFORMA

INFORMATION SHEET
CONSENT FORM

ETHICAL COMMITTEE APPROVAL FORM

TURN IT IN SCREEN SHOT

MASTER CHART
 INTRODUCTION

“CHILDBIRTH IS REBIRTH FOR THE MOTHER ”

“A PREGNANT WOMAN HAS DEATH ON HER HEAD”

These ancient sayings summarize the unpredictables and

dangers faced by pregnant women.

“Women are not dying because of diseases we cannot treat.

They are dying because societies are yet to make the decision that their

lives are worth saving.”

--Mahmoud Fathalla, WHO

Maternal mortality is described as "just the tip of the iceberg",

implying that there is a base -maternal morbidity-which remains largely

undescribed

For each woman who dies, many will survive but often suffer

from life long morbidity. Since women are handicapped by the very

same conditions which cause maternal deaths,when we reduce the risk

factors for maternal deaths we can also reduce the number of women

suffering from severe morbidities.

1
 In the airline industry, an investigation of the causes and

contributing events is carried out not only when two aeroplanes collide

with each other ,but also when they pass within 100 feet of each other

because it is a potential disaster which was averted due to extraordinary

skill of the navigating team or sheer good luck.

In health care literature NEAR MISS refers to a severe life

threatening condition that did not cause death-but had the potential to

do so. An ill woman who would have died but for the good care

received or sheer good luck is a Near Miss case. . The investigation of

near-miss, provides superior information about disease burden and

indicates quality of care in mothers. It can also broaden understanding

of factors that contribute to both maternal morbidity and mortality

This is a small scale study to analyse maternal near miss

morbidity in a local setting.

2
 AIMS AND OBJECTIVES

To analyse in a local context,

incidence of MNMM

ADVERSE EVENTS leading to MNMM(as per WHO

criteria)

DISORDERS underlying MNMM (as per WHO criteria)

sociodemographic variables among MNMM

contributing factors to near miss situations

facilities and skills needed to handle these near miss

situations.

the patterns of maternal death and morbidity

3
 REVIEW OF LITERATURE AND HISTORICAL

BACKGROUND

Rochdale, an industrial town in England, in 1928, had a

MATERNAL MORTALITY RATE of over 900 per 100,000 live births,

more than double the national average of UK. This led to a lot of local

introspection and the Public health department conducted a confidential

enquiry of maternal deaths both in the community and in hospitals.

Action on the results of this public enquiry reduced the maternal

mortality to 280 per 100,000 pregnancies , the lowest in UK.

This reduction took 6 years all the more remarkable because it

happened at a time of peak economic depression. According to the

report : “it is important to know that remarkable outcomes were got by

a change in method and spirit with no change in the personnel or

substantial increase in cost”. The review reported that the leading

causes of mortality-sepsis, haemorrhage, and eclampsia – were

compounded by the mothers’ lack of knowledge on warning signs in

pregnancy and increasing use of forceps and other techniques to hasten

the delivery of women.

4
 In 1900, there were about 700 maternal deaths per 100,000 births

in the USA , the same MMR seen in developing countries today.But, a

hundred years later, maternal death has fallen precipitously to less than

10 per 100,000 births. Similar decrease has happened in other high

income countries also; the decline started even before 1900 in Sweden.

By 1950, all over the developed world MMR plateaued at levels much

below 100 for 100,000 births.

In creating the change, the introduction of new drugs and

technologies in preventing and managing obstetric complications played

an important role. But this was not enough.It was the political will to

bring these technologies into practice that made a great change. This

was made possible by two conditions:

(a) the realization that social, economic and political

empowerment of mothers was a requirement for social wellbeing and

social peace.

(b)the awareness created by professionals about the magnitude

of the problem

However,a mere change of health care models from developed

countries to developing countries was not working.To further

5
understanding on this subject, the International Conference on Primary

Health Care was conducted in 1978 by WHO and UNICEF .

In this conference, all nations decided to develop a commitment

to form comprehensive medical programmes . These addressed the

underlying social, political andeconomic resons of poor-health. It was

decided for Primary health care (PHC) to be universal.

In the 1970s and 80s, improvements in statistical techniques and

the availability of good quality data revealed the magnitude of neonatal

deaths and morbidity.But there was not much information on maternal

deaths or morbidity.It was only in 1985 that WHO conducted the first

community study on maternal deaths in developing countries.It revealed

that every year more than a million mothers are dying,mainly in

developing nations due to preventable causes.

The WHO, World Bank and UNFPA jointly conducted

6
the first Safe Motherhood Conference in Nairobi. The conference

declared that “…something can, should-indeed must-be done, starting

with the commitment of heads of states and governments”.

The Conference was the starting point of the Safe Motherhood

Initiative (SMI). Later, the Inter-Agency Group (IAG) by UNDP,

UNICEF, IPPF joined SMI . The Population Council with Family Care

International (FCI) served as an informal secretariat.

The relative neglect of women’s health compared with the

attention given to child survival and health was realized. This point was

forcefully made by Allan Rosenfield and Deborah Maine in their

outstanding article ‘Where is the M in MCH?’

In New York in 1989,the Summit for Children was held. It was

attended by executive heads of UN agencies, heads of state, NGOs and

senior representatives of international development community and

countries. Reduction in maternal mortality and increases in antenatal

attendance were some of the goals decided in the Child Summit.

World Health Day 1998 was devoted to safe motherhood by

WHO; the slogan was ‘Pregnancy is special: let’s make it safe’. Around

the world, , theatrical presentations, street parties, marches, poster

7
campaigns and media events focused on safe motherhood. In

Washington, DC, USA, high level politicians from the developing world

and executive heads of many major international agencies and the USA

first lady came together and issued a Call to Action for safe

motherhood.

In the present scenario, four powerful drivers of maternal

mortality are steadily showing improvement worldwide. First, the global

TFR has decreased from 3.70 in 1980 to 2.56 in 2008. Although the

numbers of women of reproductive age is rising, the size of the global

birth cohort has remained stable due to the decrease in TFR. There is a

direct effect of fertility on exposure to risk of maternal death. A

decrease in TFR also leads to a decrease in MMR.It is not clear whether

it is due to a causal relation or due to social change that drives both.

Second, income per head, has been rising particularly in Asia-

obviously, this can affect maternal mortality through several channels

ranging from nutritional status of mothers to financial access to health

care.

Third, maternal educational attainment has been rising. This is

another strong correlate of maternal mortality.

8
 Finally, the increase in coverage of skilled birth attendance as in

India, may have contributed to decrease in maternal mortality

Falling numbers of maternal deaths worldwide, although a

heartening achievement, may lead to complacency; It may lead to

recommendations based on unusual events that may not be relevance to

the care of most pregnant women. The incorporation of near misses into

the maternal death enquiry system might allow for more relevant data

on maternal care being made applicable.

Maternal Death (MD) is the death of a woman while pregnant or

within 42 days of termination of pregnancy.

Live Birth (LB) refers to the complete expulsion or extraction

from its mother of a product of conception, irrespective of the duration

of the pregnancy, which, after such separation, breathes or shows any

other evidence of life. Each product of such a birth is considered

live born.

Women with life – threatening conditions (WLTC) refer to all

women who were either maternal near miss or who died. It is the sum

of maternal near miss and maternal deaths (WITC=MNM+MD).

9
 MNM incidence ratio refers to the number of maternal near miss

cases per 1,000 live births. (MNM IR = MNM/LB).

Maternal near miss: mortality ratio refers to the proportion

between maternal near miss cases and maternal deaths. Higher ratios

indicate better care (MNM : 1MD)

10
 MATERIALS AND METHODS

DEFINITION OF NEAR MISS:A woman who survives a severe

life threatening condition (either after receiving emergency

medical or surgical intervention or otherwise)during pregnancy,

abortion, childbirth or within 42 days of pregnancy termination.

There were several criteria to define near miss; But in 2009,WHO

came up with a comprehensive criteria(which included clinical

,laboratory and management based criteria) for identification of

near miss.

In this study, WHO comprehensive criteria was adopted for

identification of MNMM. In this study, all the maternal near miss

cases which met the comprehensive criteria of WHO[annexure 1]

from April 2013 to November 2013 were included.

All women with severe life threatening conditions who fulfilled

the WHO criteria were identified and flagged. Their course of

hospital stay was followed closely

A total of 50 cases were included in the study

11
Each case was documented with respect to the adverse event, the

disorder and organ dysfunction.

Coordination from different specialties was obtained, the

care given was reviewed at several levels ,feedback given to

the care giving team which improved their care wherever

possible.

Those who survived were included in this study as MNMM..

Those who did not survive were not included in this study.

However, a fleeting comparison with the MNMM and MD

shall be made because the disorders and adverse events are

the same in both categories Nearly sixteen times as many

cases of near miss maternal morbidity as mortality were

identified in this study.

Patient characteristics including age, education level, parity,

booking status, whether came directly or referred from

outside, hospital where antenatal care received, whether in

12
 life threatening condition at arrival or became so later on,

Gestational age at admission, h/o previous LSCS, adverse

events, disorders, organ system dysfunction, surgical

interventions, contributing factors, need for care in HDU

setup, interventions needed in HDU, need for Blood and

blood products, mode of delivery ,Neonatal outcome, need

for other specialty intensive care ,duration of HDU stay and

duration of hospital stay were studied.

It was decided to analyse whether MNMM was more common in

teenage pregnancy or pregnancy > 35 yrs. Hence age was included in

the study.

It was decided to study whether patients came directly or were

referred from other hospitals.

This would indicate the strengths of the referral system and any

prehospital delay in seeking care

13
 Whether they were near miss at arrival or became near miss after

admission was analysed. Near miss at arrival (within 3 to 6 hrs of

admission) would reflect the effectiveness of the referral system. Patient

stable, with no disorder on admission but becoming near miss later on

would reflect the quality of care in the institution.

Among the patients who were stable on admission, the presence

of obstetric risk factors like previous LSCS, placenta previa would be

noted to see whether these contributed to the stable cases becoming near

misses later on.

The Netherlands study identified primiparity as a risk factor for

developing MNMM. It was desired to see whether any such relationship

could be noted in India. Hence Parity was included in the study.

It was decided to study interpregnancy interval to see if

Morbidity is usually associated with inter pregnancy interval <18

months.

14
 It was desired to study whether regular antenatal care would

contribute to preventing these MNMM situations. Hence, the booking

status of these patients, whether they received AN care in Government

or private hospitals were noted. In our Study, there was no indication to

comment that government hospital AN care was found wanting. The

quality of care in private and government hospitals were comparable.

.On the whole, may be AN check up may not pickup and prevent near

miss situations entirely.

Whether MNMM was common in early pregnancy(defined as

gestational age less than 28 completed weeks) or late

pregnancy(defined as gestational age greater than 28 completed weeks)

or postnatally would throw light on the disorders specific to the various

trimesters of pregnancy. Hence it was decided to study this.

The analysis of mode of delivery in this index pregnancy may

reveal whether the pattern of mode of delivery in patients with

MNMM is different from the normal patients.

15
 Maternal care started as an offshoot of neonatal care. Based on

feto infant outcome. MNMM is divided into 3 phenotypes(1):

CLASS I MNMM : maternal near miss with healthy infant

CLASS II MNMM: infant requiring NICU ADMISSION in

MNMM cases

CLASS III MNMM: maternal near miss with stillbirth or infant

death.

Feto infant morbidity would include all infants who need ICU

care and are discharged from ICU alive.

It was decided to study these phenotypes because it would

indicate how many of the maternal near misses extended into feto infant

near misses. Gestational age, birth weight of live births were noted.

A WHO study in Latin American countries showed a reduced

incidence of MNMM among women of no education, probably because

16
 of the low levels of caesarean section in them. Educational level

was included in the study to see if any such association could be seen in

this part of the world.

Being single inflicts many social disadvantages to women and

marital status was included to see if it was a risk factor for developing

MNMM.

Each MNMM patient was documented separately based on the

ADVERSE EVENT as given by WHO eg- hypertension, hemorrhage,

cardiac disease(annexure)

Each MNMM patient was classified based on the DISORDERS as

given by WHO(eg-eclampsia, severe pre eclampsia, pph, placenta

previa, placenta accreta, ectopic pregnancy).This would give an idea

about the frequency and morbidity patterns prevalent in this area.

All emergency surgical interventions to control hemorrhage

including B Lynch suturing, Bilateral uterine artery ligation, Bilateral

17
internal iliac artery ligation, caesarean hysterectomy was documented in

the study because this would indicate the skill level and quality of care

required in the management of these patients

Any underlying medical disorder in these patients such as anemia,

diabetes, hypertension was included to study their possible contributory

role in the near miss situation.

The reason for being classified as near miss, the indications for

shifting to HDU, the interventions done in HDU and the organ system

which failed/dysfunctioned was noted because this can give important

information with regard to identifying skills and health care resources

and needed to manage these cases effectively.

For example, if respiratory dysfunction, is identified as a common

form of organ dysfunction, then Oxygen saturation monitors, arterial

blood gas analysers etc, intubation skills and ventilator facilities would

be needed to manage these patients in the hospital.

18
 Duration for which HDU care was needed and duration of

hospital stay was documented.

Prolonged hospital stay was defined as hospital stay lasting for

more than 7 days

The other specialties involved in the care of each patient , the

number of patients shifted to specialty ICU for further care and the

blood components needed were documented and analysed because it

may reveal any felt needs that can be addressed.

19
 OBSERVATIONS & RESULTS

During the study period,19185 number of patients received care

in the OP[obstetrics alone] of whom 11465 were new OP patients and

7720 were old OP patients.

7592 patients were admitted and treated;

There were 5713 deliveries ;of which 2512 were Labour Natural,205

were Assisted Vaginal deliveries and 2996 were Caesarean Sections.

There were 5570 live births.

CATEGORY NO. OF PATIENTS

OUT PATIENTS(OBS) 19185

IN PATIENTS(OBS) 7592

LIVE BIRTHS 5570

NEAR MISS 50

MATERNAL DEATHS 3

TOTAL NO. OF NEAR MISS CASES: 50

TOTAL NO. OF MATERNAL DEATHS =3

20
Women with life threatening conditions=MNMM+MD=53

Maternal near miss incidence ratio=MNM/LB=o.8976

Severe maternal outcome ratio=MNM+MD/LB=0.9515

Maternal near miss: mortality ratio =MNM:1 MD=16.6:1

Motality index=MD/(MNMM+MD)=0.0566

No. of Maternal Deaths during the study period=3

[causes: Jaundice complicating pregnancy=1

Sepsis/Type1 Respiratory failure=1

Pulmonary edema/Severe Preeclampsia=1]

No. of Primigravida: 20

No. of Multigravida:26

No. of Postnatal mothers:4

No. of MNMM who were unbooked and

unimmunised = 6 of which 4 were ectopic pregnancies

21
 No. OF MNMM booked in Private hospitals = 9

No. Of MNMM booked in GOVT. Hospitals = 35

Total no. of Multigravida with h/o Previous LSCS:16

No. of Multigravida with h/o previous 1 LSCS:12

No. of multigravida with h/o previous 2 LSCS : 4

No. Of multigravida with inter pregnancy interval less than 18

months:2

No. Of multigravida with inter pregnancy interval more than 18

months:21

Total no. Of MNMM in early pregnancy(<28 wks)= 8

No. Of MNMM in first trimester: 4

No. Of MNMM in second trimester: 4

Total no. Of MNMM in late pregnancy(third trimester): 38

22
 No. Of MNMM with healthy infant [class I] = 18

No. Of MNMM with feto- infant morbidity[class II] = 16

No. Of MNMM with fetal/infant death = [class III] = 12

No. Of MNMM with live babies = 21

No. Of MNMM with live preterm delivery = 2

No. Of MNMM with live term delivery = 18

No. Of MNMM with term delivery and birth weight less than 2.5

kg= 3

No. Of babies with morbidity requiring NICU care and survived =

16

Total no. Of dead babies=12

No. Of babies with NICU care and died=1

No. Of stillbirths = 11

23
Socio-demographic characteristics:

No. Of cases in age group less than 19 yrs = 2

No. Of cases in age group 20 -29 yrs = 39

No. Of cases in age group 30 -40 yrs =9

No. Of MNMM cases who were illiterate=5

No. Of MNMM cases who had primary education=9

No. Of MNMM cases who had secondary education=28

No. Of MNMM cases who had higher secondary education=0

No. Of MNMM cases who were graduates=8

Most common adverse events associated with MNMM :

Hypertension=-26

Hemorrhage =21

Cardiac dysfunction =3

24
 Most common disorders associated with MNMM:

Eclampsia n=16 (Antepartum=10,Postpartum=5,both=1)

Severe pre eclampsia n=10 (severe=5;severe with

signs/symptoms of Imminent eclampsia=5)

Postpartum hemorrhage n=14

Placenta previa/placenta accreta n=3

Ruptured ectopic pregnancy n=4

Congenital heart disease n = 1

Rheumatic heart disease n= 1

Cardiomyopathy n= 1

No of cases which required surgical intervention to control

hemorrhage = 20

B lynch =2

Bilateral uterine artery ligation= 6

25
 Bilateral internal iliac artery ligation =4

Emergency hysterectomy = 8

Other possibly contributing disorders in MNMM cases

Anemia =7

Diabetes mellitus = 2

Gdm = 1

Hypothyroidism = 1

Major indications for transfer to HDU care :

Neurological dysfunction = 13

Circulatory collapse = 21

Need for intravenous antihypertensives = 3

Spo2 desaturation = 3

Anti failure measures =3

26
 Most common interventions in HDU;

Ventilatory support = 7

Transfusion of blood and blood products to correct circulatory

collapse = 20

Both the above = 4

Anti failure measures = 3

Intravenous antihypertensives = 3

No/of pregnancy specific causes = 47

No. Of Pre existing disorders aggravated during pregnancy =3

No. Of pregnancy specific disorders =0

No. Of incidental and accidental causes in pregnancy = 0

Reason for being classified as near miss:

Cerebral dysfunction=20

Hypovolemia necessitating >5 units of transfusion of blood

&blood products=14

27
 Emergency hysterectomy =8

Heart failure=3

Pulmonary edema=2

Impending hypovolemia which was avoided due to emergency

surgical intervention =3

Near miss on arrival [n=33]

Eclampsia n=12

Imminent eclampsia n=4

Pulmonary edema due to severe pre eclampsia n=2

Abruptio placentae + couvelaire uterus n=2

Postpartum hemorrhage n=5

Rupture uterus n=1

28
 NEAR MISS ON ARRIVAL
76.00%
74.00%
72.00%
70.00%
68.00%
NEAR MISS ON ARRIVAL
66.00%
64.00%
62.00%
60.00%
KGH
BOLIVIAN STUDY

Cardiac failure n=3

Ruptured ectopic pregnancy n=4

Near miss after admission n=17

Had disorder on admission and became near miss

n=4

Severe pre eclampsia n=4

Developed postpartum eclampsia n=2

29
 Developed signs and symptoms of imminent eclampsia

n=1

Developed DIC and PPH n=1

14
near miss after admission
13

12

10

6
4 near miss after admission
4

2
0 0
0
with disorder with no prior
disorder

30
 Had no disorder on admission but became near miss

n=13

Normal BP & urine albumin nil on admission but developed

Postpartum eclampsia n=2

Repeat LSCS proceeded to emergeny cesarean hysterectomy

= n=4

Admitted for repeat LSCS; relaparotomy done due to internal

bleeding = 4% [n=2]

Admitted for repeat LSCS;required surgical procedures to

control Hemorrhage n=1

Placenta previa /accreta proceeded to cesarean hysterectomy=

n=5

Organ system which has failed:

Hematological system=20

Central nervous system=11

Respiratory system=2

31
 Cardiovascular system=3

Cns+ hematological system=10

Cns+ respiratory system=1

Respiratory+ hematological system=4

MNMM with only one organ system involvement =36

MNMM with more than one organ system involvement=14

A minimum of 3 specialties were involved in the care of each

patient.

Average duration of hospital stay=mean 14.95 days(range 3 days

21 hrs to 44 days 8 hrs)

Average duration of HDU stay=mean 94.18 hours(range 1 hour to

336 hours )

No. Of cases referred from KGH to RGGGH = 3

For Neurological care -= 1

No.of cases referred for CCU care =2

32
 Most common investigations for which pt. Referred to RGGGH =

CT BRAIN = 6

MRI 1

EEG 1

(2) The majority of cases 66% were near miss on arrival;

Of the 15 cases which became near miss after admission,4 had

underlying preeclampsia which rapidly flared up- 2 developed

postpartum eclampsia,one developed imminent signs with a persistently

very high BP which necessitated i.v Nitroglycerine drip,and one went

into DIC and atonic PPH.That all 4 survived reflects the quality of care

in the hospital.

Among the remaining 13 cases which became near miss after

admission,the most common cause was hemorrhage.5 of them had

placenta Previa/accreta;5 had h/o previous LSCS which went in for

atonic PPH ;all 10 necessitated emergency surgical procedures to

PREVENT and manage hemorrhage. This probably reflects the

knowledge and skill level of the care giving team and the supply of

blood and blood products by the blood bank.

33
 2 cases had normal BP and U/Alb on admission but subsequently

developed eclampsia postpartum. This probably underscores the fact

that normal BP readings may be deceptive ;it should not lull our

watchful eyes into complacency. Effectively, MNMM after admission

reflects the performance of obstetric services.

34
 (3) The majority of cases 64% n=32 came directly to the hospital

.32%[n=16] had one referral between health facilities;and 4.%[n=2]had

two referrals between health facilities

MULTIPLE REFERRALS
REFERRAL STATUS IN MNMM
CASES SINGLE REFERRAL
DIRECT ADMISSION

-8 2 12 22 32

35
 (4) Majority52%[n=26] of the MNMM were multigravida

;40%[n=20] were primigravida and 8% [n=4]were postnatal mothers.

PARITY STATUS AMONG MNMM WOMEN

8%

40%
PRIMI
MULTI
POST NATAL

52%

Of the 4 mothers who became MNMM postnatally, 3 were due to PPH

and one was PP eclampsia

36
(5) 12%[n=6] of MNMM were unbooked and unimmunised; 4 of

these were ectopic pregnancy where the women themselves were not

aware of their pregnancy status;all the others were booked and

immunised, either in Government[70%] or private[18%] hospitals.

Probably even regular AN care may not pick up all the risk factors and

prevent near misses.

BOOKING STATUS OF MNMM PATIENTS

45
40
35
30
25 BOOKING STATUS OF
MNMM PATIENTS
20
15
10
5
0
BOOKED UNBOOKED

37
 (6) Among the multigravida with MNMM, only ( n=10) had

previous vaginal delivery.

PREVIOUS LSCS AND MNMM

MULTIPARA WITH NORMAL DELIVERY WITH PREVIOS LSCS

38%

62%

38
 The majority n= 16 had a previous caesarean section. Of this

,(n=12 )had previous 1 LSCS and (n=4) had previous 2 LSCS

ASSOCIATION OF PREVIOUS LSCS AND MNMM

STUDY KGH DUTCH ALL BIRTHS

STUDY NETHERLANDS

STUDY

Previous 32% 19.3% 6%

LSCS

39
 (7) Among the multigravida,the vast majority [n=24] had an

interpregnancy interval more than 18 months.

n=2 had an interpregnancy interval less than 18 months.

(8) The majority76% [n=38]of MNMM cases presented in the

third trimester ;

8% (n=4)presented in the IInd trimester-

3 were hypertensive disorders of pregnancy,

1 was abruptio placentae with couvelaire uterus.

One baby of a mother with hypertensive disorder of pregnancy

survived ; all others were still born.

40
 8%(n=4) of cases presented in the first trimester-all were

ruptured ectopic pregnancy.

TRIMESTERWISE DISTRIBUTION OF MNMM PATIENTS

% IN KGH %IN MANIPAL

STUDY

I TRIMESTER 8 12.9

II TRIMESTER 8 4.5

III TRIMESTER 76 57.2

POSTNATAL 8 27.3

41
 (9) 12 cases belonged to CLASS III MNMM.

Of the 12,one baby was a preterm low birth weight (1.7kg) of a

mother with AP eclampsia,who was admitted in NICU and died later

due to sepsis.All the rest were still births.

9 were due to hypertensive disorders of pregnancy(4 abruptio

placentae;4 eclampsia;1 imminent eclampsia)2 were cases of placenta

previa.

16 cases belonged to CLASS II MNMM.13 of these were infants

of mothers with hypertensive disorders of pregnancy;2 were infants of

mothers with heart disease;1 was infant of a mother who underwent

Repeat LSCS -proceeded to hysterectomy due to post partum

hemorrhage.

Of the term livebirths 3 had birth weight <2.5 kg; one was

infant of a mother with RHD; one was infant of a mother with previous

LSCS and placenta accreta; one was infant of a mother with anemia and

previous 2 LSCS.

42
 18 cases belonged to CLASS I MNMM;15 were term babies;3

were preterm babies;Both the preterms were infants of mothers with

Hypertensive disorders of pregnancy.

Hypertensive disorders of pregnancy are a major cause of

mortality and morbidity among infants.

PHENOTYPE OF MNMM
PHENOTYPE OF MNMM

12
CLASSIII

16
CLASSII

18
CLASS I

43
 (10) Most ie,78%[n=39] of the MNMM cases were in the age

group of 20-29 yrs;

18%(n=9) were in the age group of 30 - 40yrs;

4.%(n=2) were in the age group of <2oyrs;

There were only 6.%(n=3) over 35 years of age

The lowest age was 19 years

SOCIO-DEMOGRAPHIC CHARACTERISTICS
Category 3

AGE GROUP-30-39 YRS

Category 2

AGE GROUP 20-29 YRS SOCIO-DEMOGRAPHIC

CHARACTERISTICS
Category 1

AGE GROUP LESS THAN 19

YEARS

0 10 20 30 40

44
* The majority of MNMM 9o%(n=45) were educated.

10%(n=5) were illiterate.

56%(n=28) were educated upto secondary level(upto

class 10th)

16%(n=8) were graduates

18%(n=9) were educated upto primary level(upto class 7th)

* All the MNMM mothers were married; all were singleton

pregnancies

45
* The most common adverse event associated with MNMM was

hypertensive disorders of pregnancy(52%) followed by

hemorrhage (42%) and cardiac dysfunction.(6%)

ADVERSE EVENTS ASSOCIATED WITH

MNMM

6%

42% 52% HYPERTENSION

HAEMORRAGE
CARDIAC

46
 NO. OF MNMM WITH HYPERTENSIVE DISORDERS

WITH h/ o PREECLAMPSIA IN PREVIOUS PREGANCY = 3(6%)

(14) The most common disorders associated with MNMM were :

ECLAMPSIA 32%

PPH 28%

SEVERE PREECLAMPSIA 20%

RUPTURED ECTOPIC PREGNANCY 8%

PLACENTA PREVIA /ACCRETA 6%

CONGENITAL HEART DISEASE 2.%

RHEUMATIC HEART DISEASE 2.%

CARDIOMYOPATHY 2.%

47
 DISORDER FREQUENCYn (%)

ECLAMPSIA 16(32%)

SEVERE PRE ECLAMPSIA 10(20%)

POSTPARTUM HAEMORRHAGE 14 (28%)

PLACENTA PRAEVIA 3(6%)

RUPTURED ECTOPIC 4(8%)

CONGENITAL HEART DISEASE 1(2%)

RHEUMATIC HEART DISEASE 1(2.%)

CARDIOMYOPATHY 1(2.%)

48
 No of MNMM
16
14
12
10
8
6
4
2 No of MNMM
0

Though the most common causes of MNMM were hypertensive

disorders of pregnancy and hemorrhage, there was low mortality for

both these conditions. This implies that treatment for both these

conditions was effective in the hospital..

49
 (15) Life saving Surgical interventions to control hemorrhage

were required in 20 cases; step wise devascularisation was done.

B LYNCH suturing(n=2),bilateral uterine artery ligtion(n=6), bilateral

internal iliac artery ligation(n=4)emergency hysterectomy(n=8).

SURGICAL INTERVENTIONS IN MNMM

PATIENTS

17%

EMERGENCY
HYSTERECTOMY

44% B LYNCH SUTURE

B/L UTERINE ART. LIGATION

28%
B/L INT.ILIAC ART. LIGATION

11%

50
 7 CASES had anemia;2 were DM on insulin;1 was GDM on

insulin;1 was hypothyroid on treatment. These could have

contributed to the maternal morbidity.

All but 4 cases[severe preeclampsia with imminent signs-1,atonic

PPH -3] were shifted to HDU and managed. The major

indications for transfer to HDU were cerebral dysfunction

(convulsions) and circulatory collapse needing massive

transfusion.

No. of MNMM
18
16
14
12
10
8 No. of MNMM

6
4
2
0
Circulatory Collapse Neurological Dysfunction

51
 The most common indications for HDU care were:

CIRCULATORY COLLAPSE = 42%

NEUROLOGICAL DYSFUNCTION = 26%

NEED FOR INTRAVENOUS ANTIHYPERTENSIVES = 6%

sPO2 DESATURATION = 6%

FOR ANTI FAILURE MEASURES = 6%

MOST COMMON INTERVENTIONS IN HDU:

TRANSFUSION OF BLOOD AND BLOOD PRODUCTS

TO CORRECT CIRCULATORY COLLAPSE = 40%

VENTILATORY SUPPORT = 14%

BOTH THE ABOVE = 8%

ANTI FAILURE MEASURES = 6%

52
 No. of MNMM
18
16
14
12
10
8 No. of MNMM
6
4
2
0
Massive transfusion of Blood & Ventilatory Support
Blood Products

INTRAVENOUS ANTIHYPERTENSIVES = 6%

The most common intervention in HDU, apart from transfusion of blood

and blood products, was ventilatory support. Eclampsia drills and

training sessions in intubation skills need to be conducted on a regular

basis.

53
 94% (n=47) were pregnancy specific causes;6.%(n=3) were

pregnancy aggravated causes;14% of MNMM with

preeclampsia had h/o high BP in previous pregnancy. Early

detection of preeclampsia would go a long way in preventing

these near miss cases.

NO. OF PREGNANCY SPECIFIC CAUSES 47

NO. OF PRE EXISTING DISORDERS 3

AGGRAVATED DURING PREGNANCY

NO. OF PREGNANCY SPECIFIC 0

DISORDERS

NO. OF INCIDENTAL AND ACCIDENTAL 0

CAUSES IN PREGNANCY

54
 REASON FOR BEING CLASSIFIED AS NEAR MISS:

CEREBRAL DYSFUNCTION=40%

HYPOVOLEMIA NECESSITATING >5 UNITS OF

TRANSFUSION OF BLOOD & BLOOD PRODUCTS=28%

EMERGENCY HYSTERECTOMY FOR ANY

REASON=16%

HEART FAILURE=6%

PULMONARY EDEMA= 4%

IMPENDING HYPOVOLEMIA WHICH WAS AVOIDED

DUE TO EMERGENCY SURGICAL INTERVENTION = 6%

55
 REASON MNMM n (%)

Cerebral dysfunction 20(40%)

Hypovolemia necessitating >5 14(28%)

units of transfusion

Emergency hysterectomy 8(16%)

Heart failure 3(6%)

Pulmonary edema 2(4%)

Impending Hypovolemia ,avoided 3(6%)

due to emergency surgical
intervention

A minimum of 3 specialties [maximum of 7] were involved in the

care of these patients in HDU. That Specialty opinions were

sought from the departments of Internal Medicine, General

Surgery, Medical gastroenterology, Anesthesia, Ophthalmology,

ENT, Chest medicine, Cardiology, Neurology, Radiology &

56
Nephrology in the management of MNMM reveals the

complexity of these cases. In the Canadian study (7) 20 different

specialties were involved in the care of MNMM patients.

On an average, these patients required 14.95 days of hospital

stay and 94.18 hours of care in High Dependency Unit setting.

72%(n=36) of cases had one organ system involvement while

28%(n=14) had more than one organ system involvement. Since

HDU is a place for intensive care when one organ system is

involved and ICU is the place for intensive care when more than

1 organ system is involved, probably upgrading the HDU to ICU

may be considered to give better care to these rare but very ill

patients.

57
Since KGH is predominantly a specialty hospital for Obstetrics

& Gynecology, cases requiring superspecialty care like

cardiology or neurology were transferred to RGGGH (2 cases –

one with RHD and the other with OS ASD operated were

transferred to CORONARY CARE UNIT after obstetric

intervention was completed )

Speciality to which transfer of MNMM No. of cases

cases occurred

CORONARY CARE UNIT 2

NEUROLOGY 1

A case of Eclampsia who developed Posterior Reversible

Encephalopathy Syndrome in the postpartum period was

transferred for expert neurology care.

All 3 patients survived.

58
 The most common investigations for which patients were

referred to RGGGH were CT SCAN,MRI & EEG. Probably

availability of these investigations inside the hospital campus

may further improve the quality of care.

Investigation for which transfer of No. of cases

MNMM cases occurred

CT SCAN 3

MAGNETIC RESONANCE IMAGING 1

ELECTRO ENCEPHALOGRAM 1

59
 During the Study Period, The Cesarean Section Rate In KGH was

52.52% Of All Hospital Deliveries. The Cesarean Section Rate

Among Near Miss Women Delivering At KGH Was 88.%

Cesarean Section Rate

90.00%
80.00%
70.00%
60.00%
50.00%
Cesarean Section Rate
40.00%
30.00%
20.00%
10.00%
0.00%
All Hospital Among MNMM
Deliveries Cases

60
 Anemia & Previous caesarean section seem to be risk factors

for MNMM. Of the 21 women who had life threatening

hemorrrhage, 16 had h/o previous LSCS;7 had anemia. Both

cases of Rupture Uterus and all 3 cases of Placenta previa/accreta

had h/o previous LSCS. Perhaps a more restrained approach to

primary caesarean section will prevent MNMM due to

hemorrhage.

The Blood Bank in KGH is a WHOLE BLOOD storing unit;

Still, apart from 163 UNITS OF WHOLE BLOOD / PACKED CELLS

(mean3.7units) it has issued 107 UNITS OF FRESH FROZEN

PLASMA(mean 2.4units) AND 31 UNITS OF PLATELETS (mean

0.72units)

61
through its tie-ups with other hospitals during the care of these patients.

BLOOD COMPONENT USED No. of Units

WHOLE BLOOD / PACKED CELLS 163

FRESH FROZEN PLASMA 107

PLATELETS 31

62
 DISCUSSION

The majority of cases 66% in KGH were near miss on

arrival;This same pattern- 74% near miss on arrival- was observed in the

Bolivian study[3]

This may be attributed to failure of recognition of the seriousness

of the condition [as in the case with c/o pain lower abdomen who was

treated in a private hospital for gastritis and sent home; she landed up 4

hrs later in KGH as near miss with ruptured ectopic pregnancy]or

delayed decision to seek medical assistance [as in the case of a home

delivery with PPH]

Addressing this ‘first delay’ needs research to understand the

health seeking behaviour of the women and regular updating of

knowledge and skills among the medical fraternity. However, MNMM

on arrival also reflects the effectiveness of emergency referrals.

63
The MNMM INCIDENCE RATIO ranged from 3.8 to 12 per

1000 livebirths in developed countries(5);In the MANIPAL study

in INDIA(4) it was 17.8 /1000 live births. In the KGH study,

it was 0.89/1000 live births. This is comparable to the incidence

in high income countries where it is between 0.5 and

1%(5)(10)

Study KGH Manipal High Income

Study Countries

MNMM 0.89 17.8 0.5

Incidence

Ratio

64
THE MNM:MORTALITY RATIO in Western Europe was

117-223 : 1. It was 5.6:1 in the Manipal study and16.6:1 in the

KGH study

Study KGH Western Manipal

Europe

MNMM : 16.6 : 1 117-223 : 1 5.6 : 1

Mortality
Ratio

65
 MODE OF DELIVERY in the index pregnancy in MNMM

by caesarean section was 43.6% in the Dutch survey (5) and

13% in the Netherlands study(5) ;63% in the Bolivian study(3);it

was 88% in the KGH study. (27)

Study Dutch Bolivian KGH Study All Births

Survey Study Netherlands
Study

Delivery by 43.6% 63% 88% 13%

Caesarean in
MNMM

During the study period, the cesarean section rate in KGH was

52.52% of all hospital deliveries. The cesarean section rate

among

66
NEAR MISS women delivering at KGH WAS 88%.In the

Bolivian study, the caesarean section rate among hospital

deliveries was 28%;in MNMM cases it was 63%.In the Canadian

study ,about 50% of MNMM patients required CESAREAN

SECTION

MODE OF DELIVERY WAS ASSISTED VAGINAL

DELIVERY in 12.7% in the the Dutch study(5) and 8.6% in the

Netherlands study(5) ;it was 4% in the KGH

HOME DELIVERY complicated by MNMM was 6.3% in the

Dutch study(5) and 31.6% in the Netherlands study(5) and 9.5%

in the Bolivian study ;it was 4% in the KGH study. Probably this

reflects the institutionalisation of births in India which favours

the early identification and management of peripartum

complications.

67
 Study Dutch Bolivian KGH Study All Births
Survey Study Netherlands
Study

Home 6.3% 9.5% 4% 31.6%

Delivery

RISK FACTORS OF MNMM: Being older than 35 years, not

having a partner, being a primipara or para > 3, and having had a

Caesarean section in the previous pregnancy were factors

independently associated with the occurrence of severe maternal

morbidity. (11)

AGE >35 was a significant risk factor in both the dutch [29.3%]

and the Netherlands study[24.7%].(5)It was not significant in the KGH

study [6%]probably because of the early age of marriage and social

pressure not to postpone childbirth in India.

68
 PREVIOUS LSCS: In the Dutch study,19.3% of MNMM had a

h/o previous Cesarean section; In the Netherlands study,6% had h/o

prior caesarean section;In the KGH study,32% of MNMM had h/o

previous Cesarean section

In the Dutch study, primiparity, diabetes, hypertension and prior

caesarean section were identified as risk factors for developing MNMM.

In the KGH study, multiparity, anemia ,diabetes and previous caesarean

section seem to be risk factors for developing MNMM. In the

Abbotabad study (8)anemia 37% and diabetes 10% were identified as

risk factors.

REFERRAL PATTERNS IN MNMM

In the KGH study, the majority of cases 64% came directly to the

hospital 32% had one referral between health facilities; and 4% had two

referrals between health facilities. This pattern of health seeking

behaviour is comparable to the pattern in the BOLIVIAN study (3)

where the majority58% of cases came directly to the hospital, 36%had

one referral between health facilities and 6%had two referrals between

health facilities.

69
 No. of MNMM
30

25

20

15
No. of MNMM
10

0
Came Directly to One Referral More than 1 Referral
Hospital between Health between health
Facilities facilities

Distribution of MNMM in early and late pregnancy:

In the Bolivian study,26% of MNMM presented in early pregnancy.

Most of them were related to pregnancy termination-which is a

sensitive, legally restricted issue in Bolivia. In the KGH study only

16% of MNMM presented in early pregnancy(<28 wks).They were due

to hypertensive disorders of pregnancy( in IInd trimester) and ruptured

ectopic pregnancy (in Ist trimester). Probably because of the MTP act

and legalisation of abortion in India, there were no MNMM attributable

to pregnancy termination in the KGH study.

70
 MNMM KGH STUDY BOLIVIAN STUDY

Most common cause in Hypertension Hemorrhage

early pregnancy disorders of

pregnancy

Percentage of MNMM 16% 26%

in early pregnancy

In the KGH study, majority 76% of MNMM were in late

pregnancy (> 28 weeks). This pattern is similar to the Manipal study(4)

where 57.2% of MNMM presented in late pregnancy.

The proportion of MNMM who presented in the postnatal period

was higher (27.3%) in the Manipal study(4) than in the KGH study

where it was only 8%(n=4).The most common cause(n=3) of MNMM in

the postnatal period in the KGH study was PPH ; the other cause

(n=1)was Postpartum eclampsia following a preterm home delivery.

71
In the Bolivian study, sepsis(1.4/1000) and obstructed

(0.4/1000)labour were uncommon causes of MNMM. These

causes are not to be found in the KGH study, probably due to the

widespread use of partographs in monitoring labour.

SOCIO DEMOGRAPHIC CHARACTERISTICS: In the KGH

study, most of the MNMM cases 78% were in the age group of

20-30 yrs; there was no one younger than 19 yrs; 6% were aged>

35 yrs.

In the Bolivian study mean age was 28 yrs(SD=7.1).In the

Manipal study, the mean age was 27.0+/-4.7. All over the world a

vast majority of women in the prime of youth are exposing

themselves to the risk of pregnancy and its attendant morbidities.

72
 Age Distribution of MNMM
Less than 20
4%

30-40 years
18%

20 - 30 Years
78%

In the KGH study,majority of MNMM patients 90%(n=45) were

educated.

10%(n=5) were illiterate.

56%(n=28) were educated upto secondary level(upto class 10 th)

16%(n=8) were graduates

73
 18%(n=9) were educated upto primary level(upto class 7th).

This pattern is similar to the Bolivian study where 3.5% were

illiterate,38% had primary education,44.5% had secondary education

and 14% had higher education.

No of MNMM
30 28

25

20

15
9 8 No of MNMM
10
5
5
0
0
Illiterate Primary Secondary Higher Graduate
Education Education Secondary
Education

PRIMARY - UPTO CLASS 7TH

SECONDARY - UPTO 10TH

74
 IN the KGH study,52% of MNMM were multigravida(26) while

34% were primigavida(n=17)This pattern reflects the Bolivian

study where 56% were multipara but differs from the Dutch study

where the higher occurrence of nulliparity seems to be a risk

factor for developing MNMM.

In the KGH study,[n=6] of MNMM were unbooked and

unimmunised;4 of these were ectopic pregnancy and the women

were not aware of their pregnancy; only n=2 antenatal mothers

were unbooked; all the others were booked and immunised, either

in Government or private hospitals. This is in contrast to the

Kathmandu study where 75% of cases were unbooked in the

hospital .In the Abbotabad study,96% of the mothers were

unbooked(8).

Study KGH Study Kathmandu Abbottabad

Study Study

No. of 4.% 75% 96%

Unbooked
MNMM

75
 In the Bolivian study(3) 88% of MNMM were either married or

cohabiting while 12% were single . All MNMM were married in

the KGH study; This probably reflects the universality of

marriage in this part of the world.

ANALYSIS OF THE CAUSES OF MNMM(adverse events)

In the Netherlands, the most frequent cause of MNMM (5)was

Major Obstetric Hemorrhage(4.5 per 1000 births) while the most

frequent cause of maternal deaths was (pre-)eclampsia.

In Pretoria, Obstetric hemorrhage, Hypertension and sepsis

account for 26%,26% and 20% of MNMM(6)

In the Manipal study, obstetric Hemorrhage 44.2%,Hypertensive

disorders 23.6%,sepsis 16.3%,cardiac 4.5% were the most common

causes.

In the Abbottabad study(8),the most frequent cause was

Hypertension 50%,sepsis 17% and Hemorrhage 13%.

76
 In the KGH study, Hypertensive disorders of pregnancy(52%) ,

Major obstetric Hemorrhage(42%) and Cardiac causes (6%) were the

common causes.

The incidence of obstetric hemorrhage in KGH was 3.77 per

1000 live births which is comparable to the Netherlands National

study(5)

ANALYSIS OF THE CAUSES OF MNMM-is there any

difference between MNMM on arrival and MNMM after

admission?

In the KGH study,34.% became near miss after admission to

hospital. The most common adverse event in this group of patients was

Hemorrhage.

In the KGH study,66% were near miss at the time of arrival;

majority of them had Hypertensive disorders of pregnancy as the

adverse event.

77
 This pattern is also reflected in the Bolivian study where 59% of

near miss on arrival were due to Hypertensive disorders of pregnancy

and 85% of near miss after admission were due to Hemorrhage.

ORGAN SYSTEM DYSFUNCTION

In the Pretoria study(6), the most common organ system

dysfunction was vascular dysfunction(hypovolemia) 37%;the same was

true of the Kathmandu study;

Study KGH Pretoria Study Kathmandu

Study

Most Common Hematological Vascular Vascular

Organ System System Dysfunction Dysfunction

Dysfunction

78
 In the KGH study also, the most common organ system

dysfunction was the haematological system(both vascular and

coagulation system were included under the same head)

Obstetric hemorrhage, though not an important cause of

maternal mortality, is still a main cause of MNMM .Preventive

measures, protocols and resources for the management of APH and PPH

and Skill training in management of obstetric emergencies on a regular

basis is important to keep this ground won

A strategy to provide access to good quality and up-to-date

information to the entire team should be in place.Obstetric

haemorrhage is not an important cause of maternal mortality,

but is still present as a major cause of severe maternal morbidity.

Preventive measures, protocols and resources for the

management of ante or postpartum haemorrhage must not only be

maintained, but improved, despite the fact that haemorrhage is not

a major cause of mortality

79
 More than 1 organ system was involved in 28% of MNMM patients

in the KGH study ; this was similar to the Kathmandu study where

26.92% had more than 1 organ system involvement

The MNMM cases required hospital care for 13 days [mean 13

days ; range 3 to 92 days] in the study by Baskett et al.

In the KGH study, the MNMM cases required hospital care for

a mean of 14.9 days[range 3 days 21 hours to 44 days 8 hours]

HDU care was required for a mean of 94.18 hrs[range 1 hour to

336 hours]

53% of MNMM required blood and blood products; of these 26

received red cells[mean=8 units];4 cryoprecipitate[mean 10

units]12 albumin[mean 4 units]15 platelets [mean=14 units]14

fresh frozen plasma[mean 8 units].In the KGH study, apart from

163 UNITS OF WHOLE BLOOD / PACKED

CELLS(mean3.7units) 107 UNITS OF FRESH FROZEN

PLASMA (mean 2.4units) AND 31 UNITS OF PLATELETS

(mean 0.72units) have been used during the care of these

MNMM patients.

80
 Numerically, haemodynamic compromise was the most common

system dysfunction.

The limitation of the study is that it is done over a relatively short

period; when done over a span of years it can be useful to assess the

efficacy of improvement measures implemented and the long term

effects of MNMM.

81
 SUMMARY AND CONCLUSIONS

The MNMM INCIDENCE RATIO in this study is 0.8 per 1000

live births.This is comparable to High income developed

countries where it is between 0.6 and 1%.

Hypertensive disorders and Hemorrhage and are the leading

causes of near miss situations .

Previous LSCS and Anaemia seem to be risk factors for

developing MNMM.

The Mortality Index is low;at 0.05,it reflects good quality of care

The causes of Near Miss reflect the causes of maternal death.

Near miss analysis is worth presenting in national indices as a

surrogate for maternal death.

82
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Near miss maternal morbidity and maternal mortality at

Kathmandu Medical College Teaching Hospital Shrestha NS1, Saha
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(3) Priorities in emergency obstetric care in Bolivia-maternal mortality and

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(5) Severe acute maternal morbidity in high –income countries Jos van
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(7) Maternal intensive care and near-miss mortality in obstetrics

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 Definition and Criteria for Maternal Near Miss

Definition:

“A woman who survives severe life threatening conditions, either after

receiving emergency medical/surgical interventions or otherwise; during
pregnancy, abortion, child birth or 1ithin 42 days of pregnancy termination” is
called as Maternal Near Miss.

1. Overall this definition of Near Miss is based upon the patient’s obvious
life threatening condition; however we need to know which disorderslead
to which adverse events, which finally cause Near Miss situation. The
conditions known to cause Near Miss are –

1.1 Pregnancy Specific Disorders such as Abortions, Ectopic Pregnancy,

Gestational Trophoblastic Disease, Antepartum Haemorrhage
(Placenta Previa and Placental Abruption), Severe Preeclampsia,
Eclampsia and HELLP syndrome, Prolonged Rupture of Membranes
with Chorioamnionitis, Third Stage complications (inversion of
Uterus, Retained Placenta, Cervical Vaginal Tear). Complications of
Induced labour of Caesarean Section, Rupture Uterus, Scar
Dehiscence, Amniotic Fluid Embolism, Postpartum Haemorrhage,
Postpartum shock, Puerperal Sepsis etc.

Abortions, Placenta praevia and Atonic PPH lead to vaginal bleeding

whereas Rupture Uterus, Ectopic Pregnancy and Invasive mole might
lead to intra peritoneal bleeding and there may not be any vaginal
bleeding. Amount of bleeding leading to circulatory collapse should
be considered as Near Miss. This might differ according to pre-
existing haemoglobin status and or the rapidity with which blood loss
occurs.
 Woman with Septic shock with hyperpyrexia, tachycardia, tachypnoea,
evidence of pus in viscera or intraperitoneally, injury to bladder/ bowel,
requiring resuscitative procedure should be considered as Near Miss.

Hypertensive disorders complicated by Hepatic, Renal, Cardiovascular

failure, Cerebral Hemorrhage, Unconsciousness, Coma, Disseminated
Intravascular Coagulation indicate Near Miss.

1.2. Preexisting Disorders Aggravated During Pregnancy such as

Anaemia, Sickle cell Disease, Thalassemia, Leukemia, Thrombophilla,
Respiratory Disorders Tuberculosis, Cardiac Disorders (Rheumatic Heart
Disease, Congenital Heart Disease, Cardiomyopathies, Aortic Aneurysm),
Renal disorders (Medico-Renal Disease and Renal Artery Stenosis), Hepatic
Disorders (Portal hypertension with Cirrhosis), Endocrinal Disorders (Diabetes
mellitus, Thyrotoxicosis and Pheochromocytoma), AIDS etc.

Liver Disorders with deep Jaundice associated with altered

consciousness, flaps, tremors and bleeding from abnormal sites are Near Miss.

Cardiac disorders requiring cardio respiratory support are Near Miss.

Anaemia with cardio respiratory collapse or patient not maintaining

oxygen saturation and requiring cardio respiratory support is Near Miss.

Respiratory disorders requiring mechanical support and intubation

indicate Near Miss.

Carbohydrate Metabolism disorders with Loss of Consciousness, Coma,

Electrolyte Imbalance indicate Near Miss.

Thyroid excess disorder/ Pheochromocytoma which need cardio

respiratory support indicate Near Miss.
 Altered consciousness, Neurological damage in any of these conditions
indicates Near Miss.

Pregnant women are not immune to any Medical / Surgical disorders.

1.2 Pregnancy Specific Medical Disorders (Medical disorders peculiar to

pregnancy) such as Cardiomyopathy and Acute fatty liver of
pregnancy. Near Miss situation is similar as in the category of
Medical Disorders with pregnancy.

1.3 Incidental and Accidental causes in Pregnancy such as infections

such as Hepatitis (A, HIV/AIDS, Pneumonia, ARDS, Pulmonary
embolism, Myocardial infarction, Stroke, Cancers, Anaphylaxis to
drugs, Surgical emergencies, Burns, Poisoning, Trauma due to
Accident or violence, Assault etc.

Woman with trauma/accident presenting with circulatory

collapse indicates Near Miss. Woman with Anaphylaxis following
administration of a drug followed by cardio respiratory failure
indicates Near Miss.

Infections with altered consciousness indicate Near Miss and

Embolism with cardio respiratory failure indicates Near Miss.

2. Many women suffer due to pregnancy/birth related disorders or other

conditions but all do not become Near Miss, so there is a need to know
what the adverse events are and what the severity of these events is,
which make the woman Near Miss. The adverse events which need to be
included for comprehensive criteria for Near Miss are those which are
known globally, where prevention may or may not be possible and are
known to lead to Maternal Mortality. Thus the comprehensive criteria
need to be made on the basis of major responsible etiological factors.
 Thus in a seriously ill patient, the clinical symptoms, signs added
by investigate profile and interventions determine whether the woman is
suffering from a severe life threatening condition or not, so clinical
criteria become extremely important at any level of facility to diagnose
the case as Near Miss.

For each disorder a battery of investigations is needed, however

which is possible, depends on the level of facility in which the woman is
treated. Separate Intensive Care units are not available at every health
facility; however Near Miss woman needs intensive care, sometimes
cardio respiratory support and mechanical ventilation also. She may need
use of cardiotonics and massive blood / components transfusion wherever
available. As a life saving measure she may need surgical procedures
such as obstetric hysterectomy, internal iliac ligation etc.

For the comprehensive criteria of Near Miss it is essential to know

possible disorders and adverse events which lead to Near Miss.
(Annexure –I)
 ABBREVIATIONS

AN-----Ante Natal

ECl------Eclampsia

HDU----High Dependency Unit

ICU---Intensive Care Unit

LSCS----Lower Segment Caesarean Section

MD ----Maternal Death -

MMC ---- Madras Medical College, chennai

MMR—Maternal Mortality Rate

MNMM--- Maternal Near Miss Morbidity

NICU-----Neonatal Intensive Care Unit

PPH---Post partum Haemorrhage

RGGGH—Rajiv Gandhi Governent General Hospital,chennai

SNB -----Sick New Born

TFR---Total Fertility Rate

 ANNEXURE – 1

Comprehensive Criteria for Maternal Near Miss

1.1 PREGNANCY SPECIFIC DISORDERS

Adverse events
Haemorrhage
Disorders
Abortion
Spontaneous
induced
Ectopic Pregnancy
Gestational Trophoblastic Disease (Vescicular mole)
Placenta previa
Placental abruption
Scar dehiscence
Rupture uterus
Surgical injury during Caesarean Section
IIIrd Stage haemorrhage complicationsw (Inversion of uterus, retained placenta,
Cervical tear)
Post partum haemorrhage
Trauma
Symptoms
Any Bleeding causing
Unconsciousness
Air Hunger
Blackouts,
Syncopal attacks with / without severe abdominal pain
Signs
Altered consciousness
Tachycardia >120/min
Low volume pulse
Bradycardia <60/min
Tachypnea >20/min
Blood Pressure
Systolic <90 mmHg
Diastolic <60 mHg
(or fall in systolic BP 30% of basal systolic if BP known)
Investigations
Acute fall Hb < 6gm (fall in haemoglobin so as to affect oxygen saturation)
Fall in oxygen saturation below 90 % on room air for>60 min
PaO2: FiO2<200
PaCO2>50mm Hg
Platelet < 50,000 (Acute Decline in platelet count more significant)
Coagulation profile altered
Serum creatinine>3.5 mg/dL
ECG-Ischemic changes, ST inversion, elevation
Absent peripheral reflexes
Intervensions
ICU admission requiring resuscitative procedure or cardio respiratory support
Massive Blood and blood products transfusion (more than 90 ml/kg body
weight/ >5 units of blood)
Use of Cardiotonics/ Vaso pressors (Mephentine/ Dobutamine/ Dopamine etc)
Resuscitative procedure done
Emergency Surgery done for controlling the blood loss such as urgent
evacuation, laparotomy with or without hysterectomy, Internal iliac Ligation or
any suturing of tears with a background of circulatory collapse.
Sepsis
Septic
Induced
Spontaneious
Premature rupture of membranes Term/Preterm
Puerperal sepsis
Post Surgical procedures (EG. Cesarean section, laparotomy, evacuation,
manual removal of placenta, others)
High grade fever
Abdominal pain
Vaginal foul smelling discharge
Temp >39.2C
Pulse rate > 120/min
Tachypnoea>20/min
Clinical evidence of septic focus in body
Leucocytosis (>10,000/cumm)
Microbial culture positive for organisms
Ultrasound shows intra pelvic/abdominal pus like collection
Imaging modality might show bladder /bowel injuries
ICU admission for resuscitative procedure or cardiorespiratory support
Antibiotics like (Sulbactum+Cefoperazone combinations, Imepenum etc)
Blood component transfusion (upto 90 ml/kg body weight/>5 units of blood)
Use of Cardiotonics/ Vaso pressors (Mephentine/ Dobutamine/ Dopamine etc)
Resuscitative procedure done
Surgical procedure doen (laparotomy for drainage of pus, repair of bladder,
bowel)
Hypertension
Hypertensive Disorders of pregnancy (Pregnancy induced hypertension,
Preeclampsia, Eclampsia HELLP Syndrome)
Convulsions
Unconsciousness
Passage of Scanty amount of urine
BP> 160/110mm Hg
Deep Jaundice
Oliguria/ anuria
Unconsciousness, coma
Coagulation failure
Pulmonary edema
Proteinuria >1 gm/dl
S.Creatinine >3.5 mg/dL
Elevated S Bilirubin (6 mg/dL)
LDH, ALT, AST (>100 IU/L)
Thrombocytopenia <50,000
Haemolysis on peripheral smear
Coagulation profile deranged
Hypertensive retinopathy >GRADE II
Abnormal ECG (ST inversion, elevation, arrhythmias)
Cerebral Hemorrhage on CT scan
ICU admission for cardio respiratory support
Repeated doses of anticonvulsants
Mechanical Ventilation
Blood and blood products transfusion
Use of Cardiotonics/ Vaso pressors (Mephentine/ Dobutamine/ Dopamine etc)
Resuscitative procedure done
1.2 PREEXISTING DISORDERS AGGRAVATED DURING
PREGNANCY
Anaemia
Iron Deficiency
Sickle cell Disease
thallsemia
Syncopal Attack
Loss of consciousness
Severe Pallor
Jaundice
Tachycardia-pulse rate>120/min
Tachypnoea>20/min
Spleenomegaly
Anasarca
Ascitis
Signs of Congestive Cardiac failure
Hemoglobin status not able to maintain O2 saturation of 90% at room level.
Platelet <50,000
Coagulation profile altered
Elevated S Bilirubin (>6 mg/dL)
Features of Sickle cell crisis)
Massive Blood/ component Transfusion (Upto 90ml/kg/>5 units of blood)
Use of Cardiotonics/ Vaso pressors (Mephentine/Dobutamine/Dopamine etc)
Resuscitative procedure done
Respiratory Dysfunction
Asthma
Tuberculosis
Pneumonia
Breathlessness
Air hunger
High Grade fever
Chronic weight loss
Tachypnoea >20/min
Abnormal chest signs (Ronchi, Crepts, Effusion)
Cardiorespiratory failure
Various lesions on chest X ray pertaining to disease
ICU admission for resuscitation and Cardiorespiratory support, Endotracheal
intubation
Need for mechanical ventilation for more than 30 min (apart from anesthesia
related)
Cardiac Dysfunction
Rheumatic Heart Disease
Congenital Heart Disease
Cardiomyopathies
Aortic Aneurysm
Breathlessness
Palpitations
Chest Pain
Orthopnoea
Paroxysmal nocturnal dyspnoea
Tachycardia
Dyspnoea
Murmurs
Cardiomegaly
Signs of CCF
Tender Hepatomegaly
Abnormal ECG
Abnormal Echocardiography
ICU admission for resuscitation and Cardiorespiratory support.
Ventilatory support, Digitalisation Use of cardiotonics
Hepatic Dysfunction
Cirrhosis of liver
Portal hypertension
Yellowness of urine/other body parts
Convulsions
Altered behaviour
Bleeding from various sites (nose, gums, IV access ports)
Deep Jaundice
Hepatomegaly
Hepatic flaps tremors
Haematuria
Abnormal bleeding sites
Elevated Serum Bilirubin (>6mg /dL)
Abnormal liver enzymes (>100 IU /L)
Abnormal ECG
Abnormal EEG
Coagulation profile deranged
ICU admission fro resuscitation and Cardiorespiratory support
Resuscitation
Mechanical Ventilation
Massive Blood and component transfusion
Ketoacidosis Thyroid Crisis
Gestational Diabetes mellitus
Diabetes mellitus
Thyrotoxicosis
Thyroid storm
Pheochromocytoma
Loss of Consciousness
Breathlessness
Palpitations
Air Hunger
Features of Circulatory collapse
Neurological deficit
Unconciousness
Coma
Convulsions
Ketoacidosis pH <7.1 RBS>200 g/dL
Abnormal ECG
Electrolyte imbalance (Sr Na<129 K<3.2)
SrT4 elevated (>200 IU)
Low TSH (<.2 IU)
Ischaemic changes on ECG
Elevated Vinyl mandilic acid
ICU admission for cardio respiratory support
Mechanical Ventilation
Resuscitative procedures Management of Ketocidosis (insulin or glucagon)
Neurological Dysfunction
Epilepsy
Cortical vein thrombosis
Altered consciousness
Convulsions
Unconsciousness and coma
Abnormal Reflexes (Hyper or absent)
Cardio respiratory failure
Abnormal EEG
Abnormal acid-base status
Abnormal EEG
CT/MRI Head showing definite lesion
ICU admission
Resuscitative measures
Higher antibiotics
Mechanical ventilation
Renal Dysfunction/Failure
Medico renal disease
Renal Artery stenosis
Reduced/Absent Urine
Edema all over body
Breathlessness (due to volume overload)
Oliguria <400 ml urine output in 24 hours
Anuria
Unconsciousness/Coma
USG showing the lesion
Doppler USG showing stenotic renal artery
Need for dialysis
Resuscitative measures
ICU admission
1.3 PREGNANCY SPECIFIC MEDICAL DISORDERS
Liver Dysfunction/ Failure
Acute Fatty liver of pregnancy
Convulsions
Altered behaviour
Bleeding from various sites (nose, gums, IV access ports)
Deep Jaundice
Hepatic flaps tremors
Haematuria
Abnormal bleeding sites
Elevated Serum Bilirubin (> 6mg/dL)
Abnormal liver enzymes (>100 IU/ L)
Abnormal ECG
Abnormal EEG
Coagulation profile deranged
USG showing changes of Acute fatty liver
ICU admission for resuscitation and cardio respiratory support
Resuscitation
Mechanical Ventilation
Massive Blood and component transfusion
Cardiac Dysfunction/ Failure
Cardiomyopathy (Antepartum, Postpartum)
Breathlessness
Palpitations
Chest pain
Orthopnoea
Paroxysmal nocturnal dyspnoea
Abnormal ECG
Abnormal Echocardiography
X ray Chest showing Gross Cardiomegaly
ICU admission for Resuscitation and Cardio respiratory support
Ventilatory support Digitalisation Use of Cardiotonics
1.4 INCIDENTAL AND ACCIDENTAL CAUSES IN PREGNANCY
Accident/Assault/ Surgical problems
Trip or fall
Vehicular accident
Blunt trauma Abdomen
Assault
Burns
Poisoning
History of trauma or accident
Syncope
Pain (Abdominal or pertaining to specific site)
Blurred vision
Altered consciousness
Tachycardia > 120/min, low volume pulse
Bradycardia <60/min
Tachypnea >20/min
Blood pressure Systolic <90 mmHg
Acute fall Hb < 6 gm (fall in haemoglobin so as to affect oxygen saturation)
Fall in oxygen saturation below 90% on room air
ICU admission requiring resuscitative procedure or cardio respiratory support
Massive Blood
Cancers
Acute surgical condition
Bleeding
Convulsions
Altered behaviour
Diastolic <60 mmHg (or fall in systolic BP 30 % of basal systolic if BP known)
Tenderness, rigidity and guarding of anterior abdominal wall with distension
Cardio respiratory failure
Evidence of trauma/ burns
PaO2 ; FiO2<200
PaCO2>50mm Hg
Platelet <50,000 Acute Decline in platelet count more significant
Coagulation profile altered
USG showing trauma to vital organs
Imaging Modality showing Injury to bladder, bowel, liver, spleen
CT/MRI showing head injury & blood products transfusion (more 90 ml/kg
body weight/>5 units of blood)
Use of Cardiotonics/ Vaso pressors (Mephentine/ Dobutamine/ Dopamine etc)
Resuscitative procedure done
Surgical procedures done (laparotomy for intraperitoneal haemorrhage, repair of
bladder, bowel, spleen, liver, kidney, Burr hole for head injury)
Anaphylaxis
Anaesthetic drugs
Antibiotics
Anitmalarials
Oxytocics
Tocolytics
Iron preparations
Anticonvulsants
Antihypertensives
History of taking the drug
Breathlessness
Air Hunger
Syncope
Not passing urine
Altered consciousness
Tachycardia >120/min thready, low volume pulse
Bradycardia <60/min
Tachypnea >20/min
Blood pressure
Systolic <90 mmHg
Diastolic <60 mmHg (or fall in systolic BP 30% of basal systolic if BP known)
Oliguria/ Anuria
Fall in oxygen saturation below 90 % on room air
PaO2 : FiO2<200
PaCO2>50mm Hg
Proteinuria > 1 gm/dl
S.Creatine > 3.5 mg/dL
Elevated S Bilirubin (6 mg/dL)
LDH, ALT, AST (>100 IU/L)
Thrombocytopenia <50,000
Haemolysis on peripheral smear
ICU admission requiring resuscitative procedure or cardio respiratory support
Massive Blood & Blood products transfusion (more 90 ml/kg body weight/>5
units of blood)
Use of Cardiotonics/ Vaso pressors (Mephentine/ Dobutamine/ Dopamine etc)
Resuscitative procedure done
Infections
Malaria
Dengue
H1N1 viral Disease
Lower respiratory tract infections
ARDS
Meningitis
Enchephalitis
Infective hepatitis (A, B, C, E)
HIV/AIDS
High Grade Fever (with/without chills and rigor)
Yellowness of urine
Altered behaviour
Breathlessness
Altered consciousness
Temp >39.2oC
Pulse rate > 120/min
Tachypnoea > 20/min
Chest signs (Crepts, crackles, ronchi, decreased or absent air entry)
Neck rigidity
Convulsions
Coma
Bleeding from various sites
Leucocytosis (>10,000/cumm)
Toxic Granules on Peripheral smear
Low Platelets (<50,000)
Microbial Culture positive for organisms
Dengue, parachek, malarial parasite positive on ELISA/ peripheral smear
H1N1 ELISA positive
Spinal fluid positive for infection
Elevated Serum Bilirubin (>6 mg)
Abnormal liver enzymes (>100 IU)
Abnormal ECG
Abnormal EEG
Coagulation profile deranged
HBsAg positive
HIV ELISA positive
ICU admission for resuscitative procedure or cardio respiratory support
Higher antibiotics (Sulbactum + Cefoperazone combinations, Imepenum)
Blood component transfusion (upto 90 ml/kg body weight/ >5 units of blood)
Use of Cardiotonics/ Vaso pressors (Mephentine/Dobutamine/ Dopamine etc)
Resuscitative procedure done
Injectable antimalarials
Use of drugs to relieve cerebral odema (Mannitol)
Antiretroviral therapy
Embolism and Infarction
Pulmonary Embolism
Cerebral Embolism (Stroke)
Cardiac Embolism
Breathlessness
Air hunger
Collapse
Tachypnoea > 20/min
Abnormal Chest signs (Ronchi, Crepts, effusion)
Various lesions on chest X ray pertaining to disease
ICU admission for resuscitative procedure or Cardio respiratory support
Myocardial infarction)
Acute chest pain
Syncope
Cardiorespiratory failure
Abnormal EEG, ECG
CT/MRI showing Lesion
Blood component transfusion (upto 90 ml/kg body weight/ >5 units of blood)
Use of Cardiotonics/ Vaso pressors (Mephentine/Dobutamine/Dopamine etc)
Anticoagulant Therapy
Drugs to reduce Cerebral Odema (Mannitol)
Clinical criteria

Acute cyanosis loss of consciousness lasting > 12 hourse gaspinga loss of

consciousness and absence of pulse/heart beat respiratory rate >40 or <6/min
strokef shockb uncontrollable fit/total paralysisg Oliguria non responsive to fluids
or diureticsc Jaundice in the presence of pre-eclampsiah Clotting failured.

Laboratory-based criteria

Oxygen saturation<90% for > 60 minutes pH <7.1 PaO2/FiO2 <200

mmHg Lactate>5 Creatinine > 300 umol/1 or > 3.5 mg/dl Acute
thrombocytopenia (<50 000 platelets) Bilirubin> 100 umol/1or 6.0mg/dl Loss of
consciousness and the presence of glucose and ketoacids in urine.

Management –based criteria

Use of continuous vasoactive drugsi Intubation and ventilation for > 60

minutes not related to anaesthesia Hysterectomy following infection or
haemorrhage Dialysis for acute renal failure Transfusion of > 5 units red cell
transfusion Cardio-pulmonary resuscitation (CPR).

a. Gasping is a terminal respiratory pattern and the breath is convulsively

and audible caught.
b. shock is a persistent severe hypotension, defined as a systolic blood
pressure <90mmHg for> 60 minutes with a pulse rate at least 120 despite
aggressive fluid replacement (>21).
c. Oliguria is defined as an urinary output <30 ml/hr for 4 hours or <
400ml/24hrs.
d. Clotting failure can be assessed by the bedside clotting test of clotting
from the IV site after 7-10 minutes.
e. Loss of consciousness is a profound alteration of mental state that
involves complete or near-complete or near complete lack of
responsiveness to external stimuli. It is defined as a Coma Glasgow Scale
<10 (moderate or severe coma). Details on the scale on the Fig.3.
f. Stroke is neurological deficit of cerebrovascular cause that persists
beyond 24 hours or is interrupted by death within 24 hours.
g. Condition in which the brain is in a state of continuous seizure.
h. Pre-eclampsia is defined as the presence of hypertension associated with
proteinuria. Hypertension is defined as a blood pressure of at least
140mmHg (systolic) or at least 90mmHg (diastolic) on at least two
 occasions and at least 4-6 h apart after the 20th week of gestation in
women known to be normotensive beforehand. Proteinuria is defined as
excretion of 300mg or more of protein every 24h. urine samples are not
available, proteinuria is defined as protein concentration of 300mg/l or
more (> 1 + on dipstick) in at least two random urine samples taken at
least 4-6 h apart.
i. For instance, continuous use of any dose of dopamine, epinephrine of
nourepinephrine.

Organ system-based

1. Cardiac dysfunction

Pulmonary oedema: a clinical diagnosis necessitating intravenous

furosemide or intubation, Cardiac arrest.

2. Vascular dysfunction
Hypovolaemia requiring > 5 units whole blood or packed cells for
resuscitation.

3. Immunological dysfunction

Intensive care admission for sepsis

4. Respiratory dysfunction

Intubation and ventilation for more than 60 min for any reason other than for
a general anaesthetic. Oxygen saturation on pulse <90% lasting more than 60
min. The ratio of the partial pressure of oxygen in arterial blood to the
percentage oxygen in inspired air is < 3 (i.e paO2/FiO2< 3).

5. Renal dysfunction

Oliguria, defined as <400ml/24h, which does not respond to either careful

adequate intravascular rehydration or attempts at inducing a dieresis with
fourosemide or dopamine. Acute deterioration of urea to >15mmol/1 or of
creatinine to >400mmol/1.

6. Liver dysfunction
Jaundice in the presence of pre-esclampsia. Pre-eclampsia defined here as a
blood pressure > 140/90 together with > 1+ proteinuria.
7. Metabolic dysfunction
Diabetic keto-acidosis. Thyroid crisis.

8. Coagulation
A cute thrombocytopenia requiring a platelet transfusion.

9. Cerebral dysfunction
Coma in a patient lasting > 12h. Subarachnoid or intracerebral haemorrhage.

Management-based

1. Intensive care admission

For any reason

2. Emergency hysterectomy
For any reason

3. Anaesthetic accidents
Severe hypotension associated with a spinal or epidural anaesthetic.
Hypotension defined as a systolic pressure <90 mmHg lasting >60min.
Failed tracheal intubation requiring anaesthetic reversal.
 CONSENT FORM

STUDY TITLE : MATERNAL NEAR MISS

MORBIDITY-AN ANALYSIS OF 50
CASES

STUDY CENTRE : Institute of Social Obstetrics and Govt. KGH,

Chennai.

PARTICIPANT NAME : AGE: SEX: J.D.NO.

I confirm that I have understood the purpose of procedure for the

above study, I have the opportunity to ask the question and all my questions
and doubts have been answered to my satisfaction.

I understand that the investigator, regulatory authorities and the ethics

committee will not need my permission to look at my health records both in
respect to the current study and any further research that may be conducted in
relation to it, even if I withdraw from the study. I understand that my identity
will not be revealed in any information released to third parties of published,
unless as required under the law. I agree not to restrict the use of any results
that arise from the study.

I hereby consent to participate in this study

of : “MATERNAL NEAR MISS
MORBIDITY: AN ANALYSIS OF 50
CASES”
.

Signature of Investigator: Place :

Date :

Study Investigators Name Institution

Signature / Thumb Impression of patient

 INFORMATION SHEET

STUDY TITLE : MATERNAL NEAR MISS MORBIDITY-AN

ANALYSIS OF 50 CASES
"
INVESTIGATOR : Dr. M.PARAMESWARI,M. S.,OG (POST
GRADUATE)

GUIDE : Prof. Dr. RAMANI RAJENDRAN M.D., DGO.,

Professor,
Institute of Social Obstetrics
Govt. Kasturi Bai Gandhi Hospital,
Madras Medical College, Chennai- 600 003.

CHIEF CO-ORDINATOR:

Prof. Dr. DILSATH, M.D., DGO.,

Director & Professor,
Institute of Social Obstetrics
Govt. Kasturi Bai Gandhi Hospital,
Madras Medical College, Chennai- 600 003.
INDRODUCTION
Maternal near miss has now gained interest as a new
quality indicator of obstetric care. Maternal deaths, although a significant
public health problem,are rare events in absolute terms in particular when
they are studied within an individual facility.Maternal near miss situations
tend to mirror the causes of maternal deaths and therefore,incorporating
maternal near miss analysis in assessing the process of obstetric care will be a
valuable contribution in taking necessary action to improve the quality of
care.

Borrowed from the airline industry,”near miss” in health care

literature generally describes a condition that did not result in injury,illness or
damage- but had the potential to do so.However, in the context of maternal
health,the near miss term has been historically used referring to a condition
where a woman experienced a severe complication,nearly died,but survived.
From the theoretical standpoint,a woman can be
recognized as a maternal near miss case only retrospectively.By definition,a
woman needs to survive the severe complication to become a maternal near
miss case.However,it is considered clinically useful to have the possibility of
prospectively identifying the women presenting with life-threatening
conditions.At the end of the process,a woman with a life –threatening
condition will become either a maternal near miss case or a maternal death.
All selected patients will be included in this study only after
getting informed consent. Extra cost will not be incurred to the patient by this
study. Any doubt regarding this study will be willingly clarified. Results of
the study will be published.
 REASON FOR
BEING CLASSIFIED ADMN WITH pre PS
AS NEAR MISS[WHO NO DISORDER ADVERSE ANY OTHER INTER PREG I existing medical
CRITERIA THAT IS AND BECAME REASON FOR ORGAN EVENT[WH DISORDER COMTRIBUTING NTERVAL< 18 Pregnancy aggravate disorder INCI /ACCI
Pt.NAME FULFILLED] NEARMISS NEAR MISS SYSTEM O] [WHO] FACTOR mt > 18 mt h/o PIH h/o DM GDM specific d s causes
SENGENI A/P 1 d [C] Y Y o o o o o o YES o o o
veronika(mod) A/X/L o d [C&H] Y Y N o 1 o o o YES o o o
PRIYA W/O KUMAR A/P/Z o d [C] Y Y o o o o o o YES o o o
DAISY INFANTA A/D o d C&H Y Y M o o o 1o YES o o o
MALA A/U o U C&H Y Y o o 1 1 o o YES o o o
AYSHA A/L o d C&H Y Y M o o o o 1 YES o o o
mahalakshmi A o d C Y Y Y o 1 o o o YES o o o
HEMAVATHY A o d C&H Y Y o o o o o o YES o o o
MUTHAMILSELVI A o d C&H Y Y o o o o o o YES o o o
SUMATHY VASANTHAKUMARA o d C&R Y Y o o o o o o YES o o o
PRIYA KANI A o d C Y Y o o o o o o YES o o o
MALARKODI P o d C Y Y N o o o o o YES o o o
sivanandini A o d C Y Y N o o o o o YES o o o
DOWLATH BEGUM P/Z o d C Y Y o o o o o o YES o o o
JAMUNA RANI P 1 d C&H Y Y o o o o o o YES o o o
SELVAMAHA I o d C Y Y o o 1 o o o YES o o o
kodhai I o d C Y Y o o o o o o YES o o o
MANJUULA I o d C&H Y Y o o o o o o YES o o o
NIKKANTH r/a o r R Y Y o o 1 1 o o YES o o o
KRISHNAVENI a/D o h R&H Y Y o o o o o o YES o o o
VASANTHI RAJA a/r/m o r R Y Y N o 1 o o o YES o o o
geethalakshmi 1.12.13 U 1 U H E D N o 1 0 o o yes o o o
HAMEEDHA D/i o h H E D o o o o o o yes o o o
ANJALI SEKAR U 1 U R&H E D o 1 o o o o yes o o o
farzana D/i o h H E D o o 1 o o o yes o o o
PONRANI U 1 U H E F o o o o o o yes o o o
JAYACHITRA U 1 U H E D o o 1 o o o yes o o o
NITHYA PANNEERSELVAM D/i o h R&H E D o o o o o o yes o o o
AMSA BACKIARAJ U o U R&H E D o o o o o o yes o o o
DEEPA D/U 1 U H E D o o 1 o o o yes o o o
AKILA U o h H E U o o o o o o yes o o o
RADHIKA D o h H E D o o 1 o o o yes o o o
kalpana w/o veera i 1 h H E U o o 1 o o o yes o o o
CHITRAKANDDHAVEL D/U 1 U H E U M o 1 o 1o yes o o o
VINNARASI[ectopic] e o h H E e o o o o o o yes o o o
CHITRA VENKATESH[ectopic]e o h H E e o o 1 o o o yes o o o
SHANTHI[ectopic] e o h H E e o o o o o o yes o o o
SATHYA B o f c C f o o o o o o o o o
MADHUMATHI B o f c C f o o o o o o 1o o
MONIKA[seizure disorder] B o f c C f o o 1o o o 1o o

KANCHANA X o h H E Y N o 1o o o yes o o o
NADHIYA D/i 1v H E D N o 1 1o o yes o o o
ATHISAYA i 1v H E D o 1o o o o yes o o o
ABIBA BANU a o a C Y a o o 1o o o 1 o o o
VALLI P o d C Y P o o 1o o o 1 o o o
VARALAKSHMI e o h H E e o o 1o o o 1 o o o
UDHAYAKUMARI X o h H Y X o o 1o o o 1 o o o
ELAKKYA F 1h H Y D o o 1o o o 1 o o o
DEBORAH X o Y H E X o o 1o o o 1 o o o
NAVITHA BEE i 1v H Y D o o 1o o o 1 o o o

A-antepartum eclapsia ;a--severe preeclapsia ;d--cerebral dysfunction

B--cardiac dysfunction ;L--HELP ;f--cardiac
C-central
failure nervous system
C--central nervous system ;c--cardiac system ;F--placenta H-haematological
accreta system
D--atonic PPH P--postpartum eclapsia R-respiratory Y-hypertension
system
E--haemorrage ;e-- ectopic/rupture c-cardiac system
E-haemorrage
H--haemalological system ;m--mgso4 toxicity ;h--hypovolumia >5units C- cardiac
of blood
dysfunction
&products used
I--iminant eclapsia ;i--iliac/uterineartery ligation
R--respiratory system ;r--acute pulmonary oedema
U--uterine rupture//sub /total hystrecomy ;v--impending hypovolumia <5 units of blood&products used
X--abruptio placentae ;Y--hypertension ;M--diabetes
Z--PRES ;N--anaemia ;K---LSCS
o--NO ;1----YES ;L---labor natural
 ADMN
AT WITH WITH NO PREV PREV KGH TO CLASS I
ADMN REF DISORDER DISORDER 1 LSCS 2 LSCS 1-12wk 13-28 wk >28 wk PN RGGGH CLASS II CLASS III < 19 20 - 29yrs 30 -40 yrs >40 yrs ILLITERATE PRIMARY SECOND Hr.SEC GRADUATE PRIMI G2.3,4
o o o 1o o o o 1o o o 1o o o 1o 1o o o o 1o
1 1 o o o o o o 1o o o o 1 o 1o o o o 1o o o 1
1 1 o o o o o o 1o o o 1o o 1o o 1o o o o 1o
1 o o o o o o o 1o o 1o o o 1o o o o o o 1 1o
1 o o o 1o o o 1o o o 1o o o 1o o 1o o o o 1
1 o o o o o o 1o o o o 1o o 1o o o o 1o o 1o
1 o o o o o o o 1o o 1o o o 1o o 1o o o o o 1
1 1 o o o o o o 1o o o o 1 o 1o o o o 1o o 1o
1 1 o o o o o o 1o o o o 1 o 1o o o o o o 1 1o
1 o o o o o o o 1o o o 1o o 1o o o 1o o o 1o
1 1 o o o o o o 1o o 1o o o 1o o o 1o o o 1o
o 1 1 o o o o o o 1 o o 1o o 1o o o 1o o o o o
o o 1 o o o o 1o o o o o 1 o 1o o o o 1o o 1o
1o o o o o o o 1o o 1o o o 1o o o o 1o o 1o
o o o 1o o o o 1o o o o 1 1o o o o o 1o o 1o
1 1o o o o o 1o o o o o 1o o 1o o o 1o o o 1
o o 1 o o o o o 1o o 1o o o 1o o o o 1o o 1o
1 1o o o o o o 1o o o 1o o 1o o o o 1o o 1o
1 1o o o o o o 1o o o 1o o o 1o o o 1o o o o
o o 1 o o o o o 1o o o 1o o 1o o o o 1o o 1o
1o o o o o o o 1o o o 1o o o 1o 1o o o o o 1
o o o 1o o o o 1o o 1o o o o 1o o o o o 1o 1
1o o o o o o o o 1 o 1o o 1o o o o o 1o o o o
o o o 1 1o o o 1o o o o 1o 1o o 1o 1o o o 1
1 1 o o 1o o o o 1 o 1o o o 1o o o o 1o o o o
o o o 1 1o o o 1o o 1o o o 1o o o o 1o o o 1
o o o 1 1o o o 1o o o o 1o 1o o o o o o 1o 1
1 1 o o o o o o 1o o 1o 1o 1o o o o 1o o o o
1 1 o o o o o o 1o o o o 1o 1o o o o 1o o o o
o o o 1 1o o o 1o o 1o o o 1o o o o 1o o o 1
1o o o 1o o o 1o o 1o o o 1o o o o o o 1o 1
1 1 o o 1o o o o 1 o 1o o o 1o o o o 1o o o o
o o o 1o 1 o o 1o o 1o o o 1o o o o 1o o o 1
o o o 1 1o o o 1o o o 1o o o 1o o o 1o o o 1
1 1 o o 1o 1 o o o o o o o o 1o o o 1o o o o 1
1 1 o o o o 1 o o o o o o o o 1o o o o 1o o o 1
1 1 o o o o 1 o o o o o o o o o 1o o o o o 1 1o
1o o o o o o o 1o 1o 1o o 1o o o 1o o o 1o
 1o o o o o o o 1o 1o 1o o 1o o o o o o 1 1o
1o o o o o o o 1o o 1o o o 1o o o o 1o o o 1

1 1o o o o o 1o o o o o 1o o 1o o o o o 1o 1
o o o o o 1o o 1 o o 1o o o 1 o o o o 1o o o 1
o o o 1o 1o o 1 o o 1o o o 1 o o o o 1o o o 1
1 o o o 1o o o 1 o o o 1o o 1 o o o 1o o o o 1
1 o o o o o o o 1 o o o 1o o 1 o o o 1o o o o 1
1 o o o o o 1o o o o o o o o 1 o o o 1o o o o 1
1 o o o o o o o 1 o o o 1o 1 o o o o 1o o o o
o o o 1o o o o 1 o o o 1o o o 1o o o 1o o o o
1 o o o o o o o 1 o o o o 1o o 1o o o 1o o o o
o o o 1o 1o o 1 o o o 1o o o 1o o o 1o o o o
 not recd MODE OF
G5>5 P1 P2,3,4 P5&more E1 A1 A2 A3or more LIVE 0 living1 living2 living >2 AN care B&I PVT PHC GHCorporation hpKGH < 37 wk >37wk < 2kg 2 -2.5kg 2.5-3 kg 3-3.5kg >3.5kg DELIVERY
o o o o o o o o o o o o o 1o 1o o o o 1o o o o 1K
o 1o o o o o o 1o o o o 1o o o 1o 1o 1o o o o K
o o o o o o o o o o o o 1o o 1o o 1o o 1o o o K
o o o o o o o o o o o o o 1o 1o o o o 1o o 1o o K
o 1o o o o o o o 1o o 1o o o o o o 1o o o 1o o K
o o o o o o o o o o o o o 1 1o o o o 1o o 1o o o K
1o o o o o o o 1o o o 1o 1o o o o 1o o 1o o K
o o o o o o o o o o o o o 1o o 1o o 1o 1o o o o K
o o o o o o o o o o o o o 1 1o o o o 1o 1o o o o K
o o o o o o o o o o o o o 1 1o o o o 1o o o o 1o K
o o o o o o o o o o o o o 1 1o o o o o 1o o 1o o K
o 1o o o o o o o 1o o 1o o o o o o 1o 1o o o o Q
o o o o o o o o o o o o o 1o 1o o 1 1o 1o o o o Q
o o o o o o o o o o o o o 1o o 1o o 1o o o 1o o Q
o o o o o o o o o o o o o 1o 1o o o 1o o 1o o o K
o 1o o 1 1o o o 1o o o 1o 1o o o 1o 1o o o o Q
o o o o o o o o o o o o o 1o o 1o o 1o o 1o o o K
o o o o o o o o o o o o o 1o o 1o o 1o 1o o o o K
1o 1 o o 1o o o o 1 o o 1 1o o o o o 1o o 1o o Q
o o o o o o o o o o o o o 1o 1o o o o 1o o 1o o K
o 1o o o o o o o 1o o o 1o 1o o o o 1o o 1o o K
o o 1 o o o o o o o 1 o o 1 1o o o o 1o 1o o o K
o 1o o o o o o o 1o o o 1o 1o o o o 1o o 1o o Q
o o 1 o o o o o o o 1 o o 1o o o o 1o 1o o 1o o K
o o 1 o o o o o o o 1 o o 1o 1o o o o 1o o 1o o K
o 1o o o o o o o 1o o o 1o o 1o o o 1o o 1o o K
o 1o o o 1o o o 1o o o 1o 1o o o 1o o 1o o o K
o 1o o o o o o o 1o o o 1o 1o o o o 1o o 1o o K
o 1o o o o o o 1o o o o 1 1o o o o o 1o 1o o o K
o 1o o o o o o o 1o o o 1o 1o o 1o 1o o 1o o K
o 1o o o 1o o o 1o o o o o o o o o o 1o o 1o o Q
o o 1 o o o o o o o 1 o o 1o 1o o o o 1o o 1o o K
o o 1 o o o o o o o 1 o o o o o o o o o 1o o 1o o Q
o 1o o o o o o o 1o o o 1o o o o 1 1o 1o o o o K
o 1o o o o o o o 1o o o o o o o o o o o o o o o o Q
o o 1 o o o o o o 1o o o o o o o o o o o o o o o o K
o o o o o o o o o o o o o o o o o o o o o o o o o o K
o o o o o o o o o o o o o 1 1o o o 1 1o 1o o o o Q
o o o o o o o o o o o o o 1 1o o o o 1o o 1o o o K
o 1o o o o o o o 1o o o 1o o o o 1o 1o 1o o o Q
emerrgency
o 1o o o o o o o 1o o o o o o o 1o 1o 1o o o o hysterotomy
o o 1o o 1o o o 1o o o 1o o o o 1o 1o 1o o o U
o o 1o o o o o o 1o o o 1o o o o o o 1o o o 1o K