Cohort study of near-miss maternal mortality and subsequent reproductive outcome

doi:10.1016/S0301-2115(01)00320-7

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 102, Issue 2, 10 May 2002, Pages 173-178

https://doi.org/10.1016/S0301-2115(01)00320-7 Get rights and content

Abstract

Objective: To determine the aetiology and outcome of near-miss mortality in obstetrical patients and the subsequent reproductive outcome where fertility is conserved. Study design: Retrospective cohort study of 51,576 women delivered at a University teaching hospital of whom 50 required transfer for critical care. Results: Over the 12 year study period 1988–1999, 50 women required transfer for intensive care (0.97/1000) and there were three maternal deaths (5.8/100,000). The main indications for transfer were hypertensive disease (32%), haemorrhage (24%) and maternal cardiac disease (24%). The perinatal mortality rate was 14%. Thirty two women conserved their fertility potential and 16 had subsequent healthy liveborn children. Conclusions: This study of near-miss maternal mortality reminds us of the need for continuing vigilance in the provision of obstetrical care. The successful reproductive outcome highlights the resilience of many women to adverse events in pregnancy but the high loss of fertility potential reflects the physical and psychological morbidity incurred.

Introduction

Maternal death is now an uncommon event in developed countries [1], [2], [3] and it has been suggested that an evaluation of near-miss mortality cases may reflect more accurately on standards of maternity care [4], [5]. Near-miss mortality is difficult to define, but can be more objectively represented by women requiring transfer to an intensive care unit (ICU). Some centres, particularly in North America, have introduced obstetric ICUs or high dependency areas attached to the delivery suite [6], [7], [8]. The admission criteria to these units differ from those for admission to a medical or surgical ICU and make comparisons of outcome difficult. In the United Kingdom, critically ill obstetric patients are usually managed on the delivery suite in the first instance and are then transferred to an ICU where intensive care can be initiated. These women represent the severe end of the spectrum of near-miss maternal mortality. There has been little consideration to date of the longer-term effects on women experiencing near-miss maternal mortality, particularly in terms of subsequent fertility potential and reproductive outcome. We have undertaken a 12 year review of obstetric admissions to our ICU, CCU and neurosurgical ICU, and compare our experience with published data from other units. We report the maternal morbidity and mortality, perinatal mortality and subsequent reproductive outcome associated with these pregnancies.

Section snippets

Methods

St. Michael’s Hospital is a University teaching hospital which delivers approximately 5000 women each year. Women are also admitted in early pregnancy to the gynaecology wards and this review includes abortion and ectopic pregnancy. Patients who encounter severe complications in pregnancy are managed in the first instance on the delivery suite where incubation, ventilation, central venous pressure and arterial lines can be established but critically ill patients need to be transferred to the

Results

Of the 51,756 women delivered in the 12 year study period, 50 required transfer for intensive care (0.97/1000). One woman was transferred to the neurosurgical unit, 2 were transferred to CCU and the remaining 47 were transferred to the ICU. The intensive care admission rate, maternal mortality and perinatal mortality for the study population are compared to the results for other centres in Table 1.

The maternal age distribution was similar to the hospital population with 37 women (74%) aged

Discussion

The indications for intensive care described in this study correspond closely to the ICU admissions reported in the confidential enquiries into maternal deaths [1], suggesting that this is an appropriate group of patients to study in terms of near-miss maternal mortality. Hypertensive disease, haemorrhage, maternal cardiac disease and sepsis account for the majority of admissions and this finding is consistent across many centres World-wide [9], [10], [11], [12], [13], [14], [15], [16], [17],

Acknowledgements

The authors wish to thank Ms. Eleanor Ferris for her help in identifying information from the maternity database and in retrieving case records.

References (20)

W.C. Mabie et al.
Treatment in an obstetric intensive care unit
Am. J. Obstet. Gynecol.
(1990)
S.J. Kilpatrick et al.
Obstetric patients requiring critical care: a five-year review
Chest
(1992)
N.A. Collop et al.
Critical illness in pregnancy: an analysis of 20 patients admitted to a medical intensive care unit
Chest
(1993)
R.W. Rochat et al.
Maternal mortality in the United States: report from the maternal mortality collaborative
Obstet. Gynecol.
(1988)
U. Hogberg et al.
Maternal mortality in Sweden, 1980–1988
Obstet. Gynecol.
(1994)
Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1994–1996. London: HMSO,...
C. Fitzpatrick et al.
Near-miss maternal mortality
Irish Med. J.
(1992)
J.O. Drife
Maternal “near-miss” reports?
BMJ
(1993)
B.K. Young et al.
Intrapartum maternal and fetal monitoring: the obstetric intensive care unit
Int. J. Gynaecol. Obstet.
(1978)
R. Johanson et al.
Obstetric intensive care at Groote Schuur Hospital, Cape Town
J. Obstet. Gynaecol.
(1995)

There are more references available in the full text version of this article.

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Citation Excerpt :
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Rationale for a Long-term Evaluation of the Consequences of Potentially Life-threatening Maternal Conditions and Maternal "Near-miss" Incidents Using a Multidimensional Approach
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Recent advances in health care mean that women survive severe conditions and events related to pregnancy that would previously have resulted in death. Therefore, a greater number of women will experience significant maternal morbidity with significant consequences. Little is known, however, about these long-term consequences. Some investigators have evaluated the repercussions of severe biological or traumatic events, and have reported that survivors are at an increased risk of death in the five years after the event. In addition, they continue to experience both organic and emotional problems such as clinical, cardiac, respiratory, and neurological complications, as well as anxiety and depression, following discharge from hospital. Following a maternal “near-miss” incident, various life domains may be affected (organic, mental, cognitive, and social function), and these must be evaluated in addition to the related economic issues and quality of life. However, because of the diversity of methods and instruments used to evaluate possible repercussions, comparisons between the few studies available on the subject are difficult. An in-depth debate should be initiated to discuss the methodological aspects of such investigation. We propose a conceptual and methodological discussion on the long-term repercussions of severe maternal morbidity based on the evaluation of the following variables: reproductive health, quality of life, posttraumatic stress syndrome, sexual function, postpartum depression, daily functioning, and the physical, neurological, and psychomotor development of the children born after a complicated pregnancy.
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Cohort study of near-miss maternal mortality and subsequent reproductive outcome

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgements

Am. J. Obstet. Gynecol.

Chest

Chest

Maternal mortality in the United States: report from the maternal mortality collaborative

Obstet. Gynecol.

Maternal mortality in Sweden, 1980–1988

Obstet. Gynecol.

Near-miss maternal mortality

Irish Med. J.

Maternal “near-miss” reports?

BMJ

Intrapartum maternal and fetal monitoring: the obstetric intensive care unit

Int. J. Gynaecol. Obstet.

Obstetric intensive care at Groote Schuur Hospital, Cape Town

J. Obstet. Gynaecol.