Maternal near miss and potentially life-threatening condition determinants in patients with type 1 diabetes mellitus at a university hospital in São Paulo, Brazil: a retrospective study

BACKGROUND

To date, the rates of potentially life-threatening condition (PTLC), maternal near miss (MNM) and maternal deaths in pregnant patients with type 1 diabetes mellitus (T1DM) and variables associated to it have not been studied.

METHODS

This study was as a cross-sectional retrospective study conducted at São Paulo Hospital of Universidade Federal de São Paulo, a tertiary hospital that provides public medical care through the Brazilian unified health system to high-risk pregnancies. Inclusion criteria were T1DM pregnant women who delivered from January 2005 to December 2015. Three groups were established by the World Heath Organization criteria and associations were assessed using the chi-square test in between MNM and no morbidity or PLTC and no morbidity. A P value < 0.05 was considered statistically significant.

RESULTS

The final sample included 137 patients, 8 MNM cases (5.84%), 51 PLTC (37.23%), no cases of maternal deaths and 78 patients (56.93%) did not present any complication. Moreover, there were 122 live births, resulting in a near miss rate of 65.5 per 1.000 live births in patients with T1DM. Two of the MNM cases were for clinical criteria (uncontrollable fit in both) and laboratory criteria for the other six: one patient with severe acute azotemia (creatinine > 300 μmol/ml), one patient with severe hypoperfusion (lactate > 5 mmol/L) and four of them with loss of consciousness and the presence of glucose and ketoacids in urine. PLTC criteria were studied in MNM and PLTC cases. Prolonged hospital stay was the most prevalent PLTC criteria in both groups (100% of MNM cases and 96% of PLTC), followed by renal failure in 50% of MNM cases and severe preeclampsia in 22% of PLTC cases. This study could not find any association between prenatal factors or sociodemographic characteristics with maternal morbidity.

CONCLUSIONS

MNM rate in T1DM was extremely high, and determined by complications of the primary disease or hypertensive disorders. No sociodemographic variables studied were related to maternal morbidity; therefore, we could not predict what increases MNM and PLTC in this specific population.

Substance use disorders and risk of severe maternal morbidity in the United States

BACKGROUND

The contribution of substance use disorders to the burden of severe maternal morbidity in the United States is poorly understood. The objective was to estimate the independent association between substance use disorders during pregnancy and risk of severe maternal morbidity.

METHODS

Retrospective analysis of a weighted 53.4 million delivery hospitalizations from 2003 to 2016 among females aged>18 in the National Inpatient Sample. We constructed measures of substance use disorders using diagnostic codes for cannabis, opioids, and stimulants (amphetamines or cocaine) abuse or dependence during pregnancy. The outcome was the presence of any of the 21 CDC indicators of severe maternal morbidity. Using weighted multivariable logistic regression, we estimated the association between substance use disorders and adjusted risk of severe maternal morbidity. Because older age at delivery is predictive of severe maternal morbidity, we tested for effect modification between substance use and maternal age by age group (18-34 y vs >34 y).

RESULTS

Pregnant women with an opioid use disorder had an increased risk of severe maternal morbidity compared with women without an opioid use disorder (18-34 years: aOR: 1.51; 95 % CI: 1.41,1.61, >34 years: aOR: 1.17; 95 % CI: 1.00,1.38). Compared with their counterparts without stimulant use disorders, pregnant women with a simulant use disorder (amphetamines, cocaine) had an increased risk of severe maternal morbidity (18-34 years: aOR: 1.92; 95 % CI: 1.80,2.0, >34 years: aOR: 1.85; 95 % CI: 1.66,2.06). Cannabis use disorders were not associated with an increased risk of severe maternal morbidity.

CONCLUSION

Substance use disorders during pregnancy, particularly opioids, amphetamines, and cocaine use disorders, may contribute to severe maternal morbidity in the United States.

Excessive gestational weight gain is associated with severe maternal morbidity

PURPOSE

We determined the association between gestational weight gain and severe maternal morbidity.

METHODS

We used data on 84,241 delivery hospitalizations at Magee-Womens Hospital, Pittsburgh, PA (2003-2012). Total gestational weight gain (kilogram) was converted to gestational age-standardized z-scores. We defined severe maternal morbidity as having ≥1 of the 21 Centers for Disease Control diagnosis or procedure codes for severe maternal morbidity identification, intensive care unit admission, or extended postpartum stay. We used multivariable logistic regression to determine the association between weight gain and severe maternal morbidity after confounder adjustment.

RESULTS

High gestational weight gain z-scores were associated with an increased risk of severe maternal morbidity. Compared with z-score 0 SD (equivalent to 16 kg at 40 weeks in a normal-weight woman), risk differences (95% confidence intervals) for z-scores -2 SD (7 kg), -1 SD (11 kg), +1 SD (23 kg), and +2 SD (31 kg) were 1.5 (-0.71, 3.7), 0.056 (-0.81, 0.93), 3.4 (1.7, 5.0), and 8.6 (4.0, 13) per 1000 deliveries. The results did not vary by gestational age at delivery or prepregnancy body mass index.

CONCLUSIONS

The increased risk of severe maternal morbidity with high pregnancy weight gain may allow scientists to understand and prevent this serious condition.

Severe maternal morbidity among U.S.- and foreign-born Asian and Pacific Islander women in California

PURPOSE

The purpose of the study was to examine the risk of severe maternal morbidity (SMM)-a composite of serious, potentially life-threatening conditions related to childbirth-among subgroups of nulliparous women with Asian and Pacific Islander race/ethnicity.

METHODS

This study used linked hospital discharge and vital record data California to identify nulliparous Asian and Pacific Islander women from 1997 to 2012 (n = 453,525). We examined the risk of SMM for 15 Asian and Pacific Islander subgroups and compared the risk between U.S.- and foreign-born women.

RESULTS

The risk of SMM was higher among Pacific Islander women than that among Asian women (148 and 127 cases per 10,000 births, respectively). Among Asian women, the risk of SMM ranged from 94 (Korean) to 165 (Filipina) cases per 10,000 births, and among Pacific Islander women, the risk ranged from 125 (Hawaiian) to 162 (Other). With the exception of Korean and Filipina women, relative risks of SMM for U.S.- versus foreign-born Asian and Pacific Islander women were similar.

CONCLUSIONS

Differences in the risk of SMM exist between subgroups of the Asian and Pacific Islander community. These differences should be considered when conducting research on racial and ethnic differences of SMM and when counseling Asian and Pacific Islander women regarding their risk of SMM.

An integrated approach to improve maternal and perinatal outcomes in rural Guatemala: A stepped-wedge cluster randomized trial

OBJECTIVE

To evaluate the impact of an intervention package on maternal and newborn health indicators.

METHODS

A randomized stepped-wedge non-blind trial was conducted across six subdistricts within two districts in Guatemala from January 2014 to January 2017. Data on outcomes were collected on all deliveries in all 33 health centers. The intervention package included distribution of promotional materials encouraging health center delivery; education for traditional birth attendants about the importance of health center delivery; and provider capacity building using simulation training. Main outcomes were number of health center deliveries, maternal morbidity, and perinatal morbidity and mortality.

RESULTS

Overall, there were 24 412 deliveries. Health center deliveries per 1000 live births showed an overall increase, although after adjustment for secular trends and clustering, the relative risk for the treatment effect was not statistically significant (aRR, 1.04; 95% confidence interval [CI], 0.97-1.11, P=0.242). Although not statistically significant, maternal morbidity (aRR, 0.78; 95% CI, 0.60-1.02; P=0.068) and perinatal morbidity (aRR, 0.84; 95% CI, 0.68-1.05; P=0.133) showed a tendency toward a decrease.

CONCLUSION

The present study represents one of the few randomized evaluations of an integrated approach to improve birth outcomes in a low-income setting. ClinicalTrials.gov: NCT0315107.

Call to action for a South American network to fight COVID-19 in pregnancy

A call to action for joint efforts by South American centers to tackle COVID‐19 in pregnancy.

Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies

Background

The debate surrounding the management of term breech presentation has excessively focused on the mode of delivery. Indeed, a steady decline in the rate of vaginal breech delivery has been observed over the last three decades, and the soundness of the vaginal route was seriously challenged at the beginning of the 2000s. However, associations between adverse perinatal outcomes and antenatal risk factors have been observed in foetuses that remain in the breech presentation in late gestation, confirming older data and raising the question of the role of these antenatal risk factors in adverse perinatal outcomes. Thus, aspects beyond the mode of delivery must be considered regarding the awareness and adequate management of such situations in term breech pregnancies.

Main body

In the context of the most recent meta-analysis and with the publication of large-scale epidemiologic studies from medical birth registries in countries that have not abruptly altered their criteria for individual decision-making regarding the breech delivery mode, the currently available data provide essential clues to understanding the underlying maternal-foetal conditions beyond the delivery mode that play a role in perinatal outcomes, such as foetal growth restriction and gestational diabetes mellitus. In view of such data, an accurate evaluation of these underlying conditions is necessary in cases of persistent term breech presentation. Timely breech detection, estimated foetal weight/growth curves and foetal/maternal well-being should be considered along with these possible antenatal risk factors; a thorough analysis of foetal presentation and an evaluation of the possible benefit of external cephalic version and pelvic adequacy in each specific situation of persistent breech presentation should be performed.

Conclusion

The adequate management of term breech pregnancies requires screening and the efficient identification of breech presentation at 36 weeks of gestation, followed by thorough evaluations of foetal weight, growth and mobility, while obstetric history, antenatal gestational disorders and pelvis size/conformation are considered. The management plan, including external cephalic version and follow-up based on the maternal/foetal condition and potentially associated disorders, should be organized on a case-by-case basis by a skilled team after the woman is informed and helped to make a reasoned decision regarding delivery route.

Neighborhood Racial And Economic Polarization, Hospital Of Delivery, And Severe Maternal Morbidity

Recent national and state legislation has called attention to stark racial/ethnic disparities in maternal mortality and severe maternal morbidity (SMM), the latter of which is defined as having a life-threatening condition or life-saving procedure during childbirth. Using linked New York City birth and hospitalization data for 2012-14, we examined whether racial and economic spatial polarization is associated with SMM rates, and whether the delivery hospital partially explains the association. Women in ZIP codes with the highest concentration of poor blacks relative to wealthy whites experienced 4.0 cases of SMM per 100 deliveries, compared with 1.7 cases per 100 deliveries among women in the neighborhoods with the lowest concentration (risk difference = 2.4 cases per 100). Thirty-five percent of this difference was attributable to the delivery hospital. Women in highly polarized neighborhoods were most likely to deliver in hospitals located in similarly polarized neighborhoods. Housing policy that targets racial and economic spatial polarization may address a root cause of SMM, while hospital quality improvement may mitigate the impact of such polarization.

Lower gestational age is associated with severe maternal morbidity of preterm cesarean delivery

OBJECTIVE

To evaluate whether gestational age was associated with the severe maternal morbidity (SMM) of preterm cesarean delivery between 22 and 34 weeks of gestation (weeks).

MATERIAL AND METHODS

We performed an observational retrospective cohort study in two tertiary university hospitals in 2018. We included all mothers of preterm infants born by caesarean delivery between 22 and 34 weeks, excluding mothers with multiple births greater than two, with pregnancy terminations or stillbirths, and who died unrelated to obstetrical causes. The principal endpoint, SMM, was a composite outcome (classical uterine incision, postpartum hemorrhage defined by blood loss ≥ 500 mL, blood transfusion, any injury to adjacent organs, unplanned procedure/need for reintervention, Intensive Care Unit (ICU) stay longer than 24 h, postpartum fever, and/or death).

RESULTS

Among the 252 women, SMM occurred in 89 (35.3 %) cases. After multivariate analysis, gestational age was independently associated with SMM (adjusted Odds Ratio [aOR] 0.87; 95 % Confidence Interval [CI] 0.78-0.97). The other variables statistically associated with SMM were type of pregnancy with a negative association with twin pregnancy (aOR, 0.44; 95 % CI, 0.20-0.93) and a positive association with general anesthesia (aOR, 2.52; 95 % CI, 1.25-5.13). A sensitivity analysis was performed and found an association, at the limit of significance, between gestational age < 28 weeks and SMM (aOR, 1.80; 95 % CI, 0.99-3.27, p = 0.05).

CONCLUSION

Lower gestational age was associated with the risk of SMM for preterm caesarean delivery between 22 and 34 weeks. Obstetricians should integrate this knowledge into their shared decision-making processes with parents.

The relationship between severe maternal morbidity and a risk of postpartum readmission among Korean women: a nationwide population-based cohort study

Background

As the rate of cesarean section delivery has increased, the incidence of severe maternal morbidity continues to increase. Severe maternal morbidity is associated with high medical costs, extended length of hospital stay, and long-term rehabilitation. However, there is no evidence whether severe maternal morbidity affects postpartum readmission. Therefore, this study aimed to determine the relationship between severe maternal morbidity and postpartum readmission.

Methods

This nationwide population-based cohort study used the Korean National Health Insurance Service-National Sample cohort of 90,035 delivery cases between January 2003 and November 2013. The outcome variable was postpartum readmission until 6 weeks after the first date of delivery in the hospital. Another variable of interest was the occurrence of severe maternal morbidity, which was determined using the Center for Disease Control and Prevention’s algorithm. The Cox proportional hazard model was used to assess the association between postpartum readmission and severe maternal morbidity after all covariates were adjusted.

Results

The overall incidence of postpartum readmission was 2041 cases (0.95%) of delivery. Women with severe maternal morbidity had an approximately 2.4 times higher risk of postpartum readmission than those without severe maternal morbidity (hazard ratio 2.36, 95% confidence interval 1.75–3.19). In addition, compared with reference group, women who were aged 20–30 years, nulliparous, and delivered in a tertiary hospital were at high risk of postpartum readmission.

Conclusions

Severe maternal morbidity was related to the risk of postpartum readmission. Policy makers should provide a quality indicator of postpartum maternal health care and improve the quality of intrapartum care.

Obstetric Comorbidity and Severe Maternal Morbidity Among Massachusetts Delivery Hospitalizations, 1998-2013

OBJECTIVES

The rate of severe maternal morbidity in the United States increased approximately 200% during 1993-2014. Few studies have reported on the health of the entire pregnant population, including women at low risk for maternal morbidity. This information might be useful for interventions aimed at primary prevention of pregnancy complications. To better understand this, we sought to describe the distribution of comorbid risk among all delivery hospitalizations in Massachusetts and its association with the distribution of severe maternal morbidity.

METHODS

Using an existing algorithm, we assigned an obstetric comorbidity index (OCI) score to delivery hospitalizations contained in the Massachusetts pregnancy to early life longitudinal (PELL) data system during 1998-2013. We identified which hospitalizations included severe maternal morbidity and calculated the rate and frequency of these hospitalizations by OCI score.

RESULTS

During 1998-2013, PELL contained 1,185,182 delivery hospitalizations; of these 5325 included severe maternal morbidity. Fifty-eight percent of delivery hospitalizations had an OCI score of zero. The mean OCI score increased from 0.60 in 1998 to 0.82 in 2013. Hospitalizations with an OCI score of zero comprised approximately one-third of all deliveries complicated by severe maternal morbidity, but had the lowest rate of severe maternal morbidity (22.8/10,000 delivery hospitalizations).

CONCLUSIONS

The mean OCI score increased during the study period, suggesting that an overall increase in risk factors has occurred in the pregnant population in Massachusetts. Interventions that can make small decreases to the mean OCI score could have a substantial impact on the number of deliveries complicated by severe maternal morbidity. Additionally, all delivery facilities should be prepared for severe complications during low-risk deliveries.

Expected Surge in Maternal Mortality and Severe Morbidity among African-Americans in the Era of COVID-19 Pandemic

Prior to the COVID-19 pandemic, African-American mothers were three times as likely to die from pregnancy-related causes compared to white mothers. The impact of the pandemic among African-Americans could further worsen the racial disparities in maternal mortality (MM) and severe maternal morbidity (SMM). This study aimed to create a theoretical framework delineating the contributors to an expected rise in maternal mortality (MM) and severe maternal morbidity (SMM) among African-Americans in the era of the COVID-19 pandemic due to preliminary studies suggesting heightened vulnerability of African-Americans to the virus as well as its adverse health effects. Rapid searches were conducted in PubMed and Google to identify published articles on the health determinants of MM and SMM that have been or likely to be disproportionately affected by the pandemic in African-Americans. We identified socioeconomic and health trends determinants that may contribute to future adverse maternal health outcomes. There is a need to intensify advocacy, implement culturally acceptable programs, and formulate policies to address social determinants of health.

Comparison of four prognostic scales for predicting mortality in patients with severe maternal morbidity

OBJECTIVE

To compare the prognostic validity of the APACHE II-M and O-SOFA scales versus the APACHE II and SOFA to predict mortality in patients with severe maternal morbidity.

DESIGN

A retrospective, longitudinal and analytical cohort study was carried out.

SETTING

Medical-surgical intensive care unit (ICU) of a tertiary hospital.

PATIENTS

Pregnant or puerperal patients of any age admitted to the ICU.

INTERVENTIONS

Calculation of prognostic scores upon admission.

VARIABLES OF INTEREST

APACHE II, SOFA, APACHE II-M and O-SOFA scores and maternal mortality.

RESULTS

A total of 141 patients were included. The majority (70.2%) were puerperal. The most frequent diagnosis was gestational hypertensive disease (50 cases). The discrimination of each prognostic model was estimated with the area under the ROC curve (AUC-ROC). The calibration was estimated using the mortality ratio and the Hosmer-Lemeshow statistic. The four scales discriminated between survivors and non-survivors with areas under the curve >0.85. The APACHE II-M model was the predictive model with the highest discrimination and calibration. In the Hosmer-Lemeshow regression analysis, mortality as predicted by the APACHE II and O-SOFA was significantly different from the observed mortality.

CONCLUSIONS

The APACHE II-M exhibited the greatest prognostic validity in predicting maternal mortality. This difference was given by its improvement in calibration.

Association between planned mode of delivery and severe maternal morbidity in women with breech presentations: A secondary analysis of the PREMODA prospective general population study

BACKGROUND

Neonatal morbidity among fetuses in breech presentation is not associated with planned mode of delivery in France. Data about consequences to these mothers are sparse.

METHODS

The prospective PREMODA study took place in France and Belgium (2001-2002) in 138 maternity units and included all women with a singleton fetus in breech presentation ≥ 37 weeks of gestation (n=8105). We excluded women with more than one previous cesarean delivery, an in utero fetal death, or for whom cesarean delivery or induction of labor was planned due to maternal disease. The composite variable "severe acute maternal morbidity" (SAMM) grouped severe events. Associations between planned modes of delivery and SAMM were estimated from multivariable Poisson regression models adjusted for potential confounders. A control group with fetuses in cephalic presentation enabled us to compare maternal complications by fetal presentation.

RESULTS

Among the 7564 women included in the analysis, 5098 (67.4%) had a planned cesarean and 2466 (32.6%) a planned vaginal delivery; their SAMM rates did not differ: 48/8098 (0.9%) versus 17/2466 (0.7%), respectively, with an adjusted risk ratio (aRR) of 1.60, 95% confidence interval (95% CI) 0.81-3.15. The SAMM rate was significantly higher in the planned vaginal breech group than in the planned vaginal cephalic group: 17/2466 (0.7%) versus 39/10156 (0.4%) (aRR 2.10, 95% CI 1.18-3.74).

CONCLUSION

In women with a fetus in breech presentation at term, the short-term risk of severe maternal morbidity did not differ significantly according to planned mode of delivery.

Severe maternal morbidity and postpartum mental health-related outcomes in Sweden: a population-based matched-cohort study

We examined whether women experiencing severe maternal morbidity (SMM) are more likely to be treated for a psychiatric illness or be prescribed psychotropic medications in the postpartum year than mothers who did not experience SMM. We also examine the relationship between SMM and specific mental health-related outcomes, and the relationship between specific SMM diagnoses/procedures and postpartum mental-health-related outcomes. The national registers in Sweden were used to create a population-based matched cohort. Every delivery with SMM between July 1, 2006, and December 31, 2012 (n = 8558), was matched with two deliveries without SMM (n = 17,116). Conditional logistic regression models assessed the relationship between SMM and postpartum mental health-related outcomes. Women who experienced SMM had significantly greater odds of being treated for a psychiatric disorder (aOR 1.22; 95% CI 1.03-1.45) and being prescribed psychotropic medications (aOR 1.40; 95% CI 1.24-1.58) in the postpartum year. Specifically, they had significantly greater odds of being treated for neuroses (aOR 1.35; 95% CI 1.09-1.69) and having a prescription for anxiolytics/hypnotics (aOR 1.36; 95% CI 1.18-1.58) or antidepressants (aOR 1.35; 95% CI 1.17-1.55). Women who were diagnosed with shock or uterine rupture/obstetric laparotomy during delivery had the greatest odds of postpartum mental health-related outcomes. This study identified mothers with SMM as a group at high risk for postpartum mental illness. Postpartum mental health services should be provided to ensure the well-being of these high-risk mothers.

Maternal near miss determinants at a maternity hospital for high-risk pregnancy in northeastern Brazil: a prospective study

Background

To investigate the association between sociodemographic and obstetric variables and delays in care with maternal near misses (MNMs) and their health indicators.

Methods

A prospective cohort study was conducted at a high-risk maternity hospital in northeastern Brazil from June 2015 to May 2016 that included all pregnant women seen at the maternity hospital during the data collection period and excluded those who had not been discharged at the end of the study or whom we were unable to contact after the 42nd postpartum day for MNM control. We used the MNM criteria recommended by the WHO. Risk ratios (RRs) and their 95% confidence intervals (CIs) were calculated. Hierarchical multiple logistic regression analysis was performed. The p values of all tests were two-tailed, and the significance level was set to 5%.

Results

A total of 1094 pregnant women were studied. We identified 682 (62.4%) women without adverse maternal outcomes (WOAMOs) and 412 (37.6%) with adverse maternal outcomes (WAMOs), of whom 352 had potentially life-threatening conditions (PLTCs) (85.4%), including 55 MNM cases (13.3%) and five maternal deaths (1.2%). During the study period, 1002 live births (LBs) were recorded at the maternity hospital, resulting in an MNM ratio of 54.8/1000 LB. The MNM distribution by clinical condition identified hypertension in pregnancy (67.2%), hemorrhage (42.2%) and sepsis (12.7%). In the multivariate analysis, the factors significantly associated with an increased risk of MNM were fewer than six prenatal visits (OR: 3.13; 95% CI: 1.74–5.64) and cesarean section in the current pregnancy (OR: 2.91; 95% CI: 1.45–5.82).

Conclusions

The factors significantly associated with the occurrence of MNM were fewer than six prenatal visits and cesarean section in the current pregnancy. These findings highlight the need for improved quality, an increased number of prenatal visits and the identification of innovative and viable models of labor and delivery care that value normal delivery and decrease the percentage of unnecessary cesarean sections.

Severe Maternal Morbidity in Canada: Temporal Trends and Regional Variations, 2003-2016

OBJECTIVE

This study sought to quantify temporal trends and provincial and territorial variations in severe maternal morbidity (SMM) in Canada.

METHODS

The study used data on all hospital deliveries in Canada (excluding Québec) from 2003 to 2016 to examine temporal trends and from 2012 to 2016 to study regional variations. SMM was identified using diagnosis and intervention codes. Contrasts among periods and regions were quantified using rate ratios (RRs) and 95% confidence intervals (CIs). Temporal changes were also assessed using chi-square tests for trend (Canadian Task Force Classification II-1).

RESULTS

The study population included 3 882 790 deliveries between 2003 and 2016 and 1 418 545 deliveries between 2012 and 2016. Severe hemorrhage rates increased from 44.8 in 2003 to 62.4 per 10 000 deliveries in 2012 (P for trend <0.0001) and then declined to 41.8 per 10 000 deliveries in 2016 (P for trend <0.0001). Maternal intensive care unit admission and sepsis rates decreased between 2003 and 2016, whereas rates of stroke, severe uterine rupture, hysterectomy, obstetric embolism, shock, and assisted ventilation increased. Rates of composite SMM in 2012-2016 were higher in Newfoundland and Labrador (RR 1.15; 95% CI 1.04-1.26), Nova Scotia (RR 1.11; 95% CI 1.03-1.19), New Brunswick (RR1.22; 95% CI 1.13-1.32), Manitoba (RR 1.09; 95% CI 1.03-1.15), Saskatchewan (RR 1.15; 95% CI 1.09-1.22), the Yukon (RR 1.74; 95% CI 1.35-2.25), and Nunavut (RR 1.76; 95% CI 1.46-2.11) compared with the rest of Canada, whereas rates were lower in Alberta and British Columbia.

CONCLUSION

This surveillance report helps inform clinical practice and public health policy for improving maternal health in Canada.

Life-threatening Complications in Pregnancy in a Teaching Hospital in Kolkata, India

Objectives

To test the application of a clinical definition of life-threatening complications in pregnancy and determine the level of near miss maternal morbidity and mortality.

Methods

A prospective observational study was conducted in the obstetrics and gynaecology department, NRS Medical College, Kolkata, India, to identify life-threatening complications using a modification of the Mantel's criteria. The main outcome measures were validity of identification criteria, main causes and incidence of life-threatening complications in pregnancy, maternal near miss: case fatality rates, morbidity-mortality index and use rate of effective interventions.

Results

In total, 177 maternal near miss and 23 maternal deaths were identified in the screened 4400 women. The incidence of near miss was 4.02%. Main causes of maternal mortality were hypertensive disorders (43%) and renal failure (21%). Main causes of near miss were hypertensive disorders (55%), ectopic pregnancy (19%). Near miss mortality index was 7.7:1.

Conclusions

A high proportion of women with life-threatening complications and all women who died were referred from peripheral hospitals. This signals that there may have been important failures in the referral system relating to maternal care and there is a need for further investigation.

Adverse perinatal outcomes are associated with severe maternal morbidity and mortality: evidence from a national multicentre cross-sectional study

PURPOSE

To assess the association between maternal potentially life-threatening conditions (PLTC), maternal near miss (MNM), and maternal death (MD) with perinatal outcomes.

METHODS

Cross-sectional study in 27 Brazilian referral centers from July, 2009 to June, 2010. All women presenting any criteria for PLTC and MNM, or MD, were included. Sociodemographic and obstetric characteristics were evaluated in each group of maternal outcomes. Childbirth and maternal morbidity data were related to perinatal adverse outcomes (5th min Apgar score < 7, fetal death, neonatal death, or any of these). The Chi-squared test evaluated the differences between groups. Multiple regression analysis adjusted for the clustering design effect identified the independently associated maternal factors with the adverse perinatal outcomes (prevalence ratios; 95% confidence interval).

RESULTS

Among 8271 cases of severe maternal morbidity, there were 714 cases of adverse perinatal outcomes. Advanced maternal age, low level of schooling, multiparity, lack of prenatal care, delays in care, preterm birth, and adverse perinatal outcomes were more common among MNM and MD. Both MNM and MD were associated with Apgar score (2.39; 1.68-3.39); maternal hemorrhage was the most prevalent characteristic associated with fetal death (2.9, 95% CI 1.81-4.66) and any adverse perinatal outcome (2.16; 1.59-2.94); while clinical/surgical conditions were more related to neonatal death (1.56; 1.08-2.25).

CONCLUSION

We confirmed the association between MNM and MD with adverse perinatal outcomes. Maternal and perinatal issues should not be dissociated. Policies aiming maternal care should include social and economic development, and improvements in accessibility to specialized care. These, in turn, will definitively impact on childhood mortality rates.

The contribution of maternal characteristics and cesarean delivery to an increasing trend of severe maternal morbidity

BACKGROUND

Severe maternal morbidity - life-threatening childbirth complications - has more than doubled in the United States over the past 15 years, affecting more than 50,000 women (1.4% of deliveries) annually. During this time period, maternal age, obesity, comorbidities, and cesarean delivery also increased and may be related to the rise in severe maternal morbidity. We sought to evaluate: (1) the association of advanced maternal age, pre-pregnancy obesity, pre-pregnancy comorbidities, and cesarean delivery with severe maternal morbidity, and (2) whether changes in the prevalence of these risk factors affected the trend of severe maternal morbidity.

METHODS

This population-based cohort study used linked birth record and patient discharge data from live births in California during 2007-2014 (n = 3,556,206). We used multivariable logistic regression models to assess the association of advanced maternal age (≥35 years), pre-pregnancy obesity (body mass index ≥30 kg/m2), pre-pregnancy comorbidity (index of 12 conditions), and cesarean delivery with severe maternal morbidity prevalence and trends. Severe maternal morbidity was identified by an index of 18 diagnosis and procedure indicators. We estimated odds ratios, predicted prevalence, and population attributable risk percentages.

RESULTS

The prevalence of severe maternal morbidity increased by 65% during 2007-2014. Advanced maternal age, pre-pregnancy obesity, and pre-pregnancy comorbidity also increased during this period, but cesarean delivery did not. None of these risk factors affected the increasing trend of severe maternal morbidity. However, the pre-pregnancy risk factors together were estimated to contribute to 13% (95% confidence interval: 12, 14%) of severe maternal morbidity cases in the study population overall, and cesarean delivery was estimated to contribute to 37% (95% confidence interval: 36, 38%) of cases.

CONCLUSIONS

Pre-pregnancy health and cesarean delivery are important risk factors for severe maternal morbidity but do not explain an increasing trend of severe maternal morbidity in California during 2007-2014. Investigation of other potential contributors is needed in order to identify ways to reverse the trend of severe maternal morbidity.

Incidence of maternal near miss in the public health sector of Harare, Zimbabwe: a prospective descriptive study

Background

Maternal ‘near miss’ can be a proxy for maternal death and it describes women who nearly died due to obstetric complications. It measures life threatening pregnancy related complications and allows the assessment of the quality of obstetric care.

Methods

A prospective descriptive study was carried out from October 1 2016 to 31 December 2016, using the WHO criteria for maternal ‘near miss’ at the two tertiary public hospitals which receive referrals of all obstetric complications in Harare city, Zimbabwe. The objective was to calculate the ratio of maternal ‘near miss’ and associated factors. All pregnant women who developed life threatening complications classified as maternal near miss using the WHO criteria were recruited and followed up for six weeks from discharge, delivery or termination of pregnancy or up to the time of death.

Results

During this period there were 11,871 births. One hundred and twenty three (123) women developed severe maternal outcomes, 110 were maternal ‘near miss’ morbidity and 13 were maternal deaths. The maternal ‘near miss’ ratio was 9.3 per 1000 deliveries, the mortality index (MI) was 10.6% and the maternal mortality ratio was 110 per 100,000 deliveries. The major organ dysfunction among cases with severe maternal outcomes (SMO) was cardiovascular dysfunction (76.9%). The major causes of maternal near miss were obstetric haemorrhage (31.8%), hypertensive disorders (28.2%) and complications of miscarriages (20%). The intensive care unit (ICU) admission rate was 7.3 per 100 cases of SMO and 88.8% of maternal deaths occurred without ICU admission.

Conclusion

The MNM ratio was comparable to that in the region. Obstetric haemorrhage was a leading cause of severe maternal morbidity though with less mortality when compared to hypertensive disorders and abortion complications. Zimbabwe should adopt maternal near miss ratio as an indicator for evaluating its maternal health services.

Temporal Variations in Incidence andOutcomes of Critical Illness Among Pregnant and Postpartum Women inCanada: A Population-Based Observational Study

OBJECTIVE

Pregnancy-associated morbidity results in hundreds of thousands of deaths annually worldwide. Reducing maternal mortality is a key United Nations Millennium Development Goal. Although maternal mortality has declined in high-income countries, contemporary estimates of maternal morbidity and mortality trends in Canada are lacking.

METHODS

This population-based study investigated all antepartum, peripartum, and postpartum women presenting to an acute care hospital in Canada from April 1, 2004 to March 31, 2015. The primary outcome was the change in rates of severe maternal morbidity over time. Secondary outcomes included severe maternal mortality and intensive care unit admission, including by province and territory (level of evidence: II2).

RESULTS

The cohort comprised 2 035 453 mothers with 3 162 303 pregnancies. There were 17.7 per 1000 episodes of severe maternal morbidity, with annual increases of 1.3% (95% confidence interval [CI] 0.60-2.0) for severe maternal morbidity. The maternal mortality rate was 6.2 per 100 000 deliveries and stable over time (estimated percentage of annual change of -0.46%; 95% CI -5.0 to 4.3). The most common causes of severe maternal morbidity were postpartum hemorrhage (5.5 per 1000 deliveries), sepsis (3.8 per 1,000 deliveries), and cardiac failure (1.5 per 1000 deliveries). Severe maternal morbidity varied across Canadian regions but was highest in the Territories at 22.8 per 1000 deliveries.

CONCLUSION

Although maternal mortality has been stable in Canada over time, rates of severe maternal morbidity are increasing and are associated with substantial regional variation, with the highest rates experienced by women in the northern Territories.

Disentangling the contributions of maternal and fetal factors to estimate stillbirth risks for intrapartum adverse events in Tanzania and Uganda

OBJECTIVE

To estimate the stillbirth risk associated with intrapartum adverse events, controlling for fetal and maternal factors.

METHODS

The present study was an analysis of cross-sectional patient-record and facility-file data from women with viable fetuses who experienced obstetric adverse events at 23 hospitals and 38 health centers in Tanzania (between December 2015 and October 2016), and 22 hospitals, 16 level-4 health centers, and five level-3 health centers in Uganda (between May 2016 and September 2017). Adverse events were categorized in three severity groups (postpartum, intrapartum non-near-miss, and intrapartum near-miss) to calculate stillbirth rates and adjusted prevalence ratios.

RESULTS

Data from 3816 women in Tanzania and 8305 in Uganda were included. Compared with postpartum adverse events, intrapartum near-miss was associated with a 3.73- and 4.55-fold higher prevalence of stillbirth in Uganda and Tanzania, respectively. Most women who experienced near-miss had organ dysfunction on arrival or developed it soon after. The risk of stillbirth was higher among preterm deliveries compared with term deliveries, and was 42% and 59% lower in Tanzania and Uganda, respectively, for cesarean deliveries compared with vaginal deliveries after intrapartum non-near-miss adverse events.

CONCLUSION

Stillbirth risk increased with severity of complications and was higher among premature deliveries. Survival was higher for cesarean deliveries in intrapartum non-near-miss complications, identifying the opportunity to prevent deterioration by timely actions.

Maternal Mortality in the Twenty-First Century

Maternal mortality plagues much of the world. There were 303,000 maternal deaths in 2015 representing an overall global maternal mortality ratio of 216 maternal deaths per 100,000 live births. In the United States, the maternal mortality ratio had been decreasing until 1987, remained stable until 1999, and then began to increase. Racial disparities exist in the rates of maternal mortality in the United States with maternal death affecting a higher proportion of black women compared with white women. To reduce maternal mortality, national organizations in the United States have called for standardized review of cases of maternal morbidity and mortality.