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Characterization of Maternal Near Miss in Two Tertiary Referral Hospitals in Developed Nations
Abstract Number: T-55
Abstract Type: Original Research
Background: More than half a million women worldwide aged 15-49 die every year due to perinatal complications with many more having severe morbidity. The World Health Organization (WHO) has defined several criteria for identifying severe maternal morbidity, termed a “near miss.” We aimed to characterize the maternal population admitted to the intensive care unit (ICU) in 2 developed countries as a representative sample of maternal near miss to study the relevance of WHO criteria in this population.
Methods: After IRB approval from both institutions, we retrospectively reviewed the charts of all peripartum ICU admissions over a 10 year period (2005-2014). Cases were identified through the hospital computerized databases. We used SPSS 20 for analysis of the partial data collected from the centers.
Results: We have collected data from 172 cases. Mean age was 31±7. Maternal medical history most commonly included hematologic (11%), cardiovascular (9%), respiratory (8%), and endocrine (7%) diseases. Almost 1/3 of the women were on medication at the time of admission including thyroid hormone replacement (7%), antihypertensives (6%), respiratory inhalers (6%) and anticoagulants (5%). The women had an obstetric history of 2.1±2.4 live births; 29% had a history of prior obstetric complication and 31% had a prior cesarean delivery. About 1/6 of the pregnancies resulted from fertility treatments.
The ICU admissions were most commonly during the 3rd pregnancy. Women presented to the hospital at 32±9 weeks, with complications occurring at 33±8 weeks. Only 9% of the cases had a prolonged or complicated delivery.
Near misses occurred most commonly postpartum (42%), followed by antepartum (39%) and intrapartum (19%). Almost 1/3 of the women presented in shock but overall 59% were in shock at some time during admission. Most events were directly related to the pregnancy (n=98, 57%). Hemorrhage (n=71) and preeclampsia (n=11) were the most common direct causes; 37.2% fulfilled criteria for massive transfusion (>5 packed cells per day). Indirect causes were mostly complications of cardiovascular disease and severe infections. Surgery to control hemorrhage (most commonly hysterectomy) was required in 48% and 22 women underwent repeat surgery. One-fifth of the women did not fulfill WHO criteria for critical illness during pregnancy. In most of these cases, admission was due to a medical complication unrelated to the pregnancy.
Conclusions: Hemorrhage and preeclampsia were the most common direct causes of maternal ICU admission, while cardiovascular disease was the most common indirect cause. The WHO criteria captured the majority of our critically ill population, but 22% did not fit the criteria. A modified classification scheme for near misses may be needed for developed countries.
Say L, et al. WHO systematic review of maternal morbidity and mortality: the prevalence of severe acute maternal morbidity (near miss). Repro Health 2004; 1:3.