Exploring Epidemiological Aspects, Distribution of WHO Maternal Near Miss Criteria, and Organ Dysfunction Defined by SOFA in Cases of Severe Maternal Outcome Admitted to Obstetric ICU: A Cross-Sectional Study

[Maternal morbidity and mortality in Brazil and the urgency of a national surveillance system for maternal near miss]

The World Health Organization (WHO) recommends the analysis of severe maternal morbidity/maternal near miss cases as complementary to the analysis of maternal deaths since the incidence is higher and the predictive factors of the two outcomes are similar. Considering that the reasons for maternal mortality in Brazil have remained constant despite the commitment made during the General Assembly of the United Nations in 2015, this article aims to propose a nationwide maternal near miss surveillance system. We propose the inclusion of maternal near miss events in the National List of Compulsory Notification of Diseases, Injuries, and Public Health Events, via the compatibility of the diagnostic criteria of maternal near miss, informed by the WHO, with the codes of the International Classification of Diseases for the identification of cases. Considering that health surveillance is based on several sources of information, notification could be made by health service professionals as soon as a confirmed or suspected case is identified. With the study of the factors associated with the outcomes, we expect a qualified evaluation of the services focused on obstetric care and consequent implementation of more efficient policies to prevent not only maternal death but also events that can both cause irreversible sequelae to women's health and increase the risk of fetal and neonatal death.

Indications and diagnosis-specific features of maternal and neonatal peripartum intensive care unit admissions: A retrospective study

BACKGROUND

Although peripartum intensive care unit admission indications are well-reported, clinical and laboratory details rarely are. We described admission indications and categorised laboratory values and vital signs according to admission diagnosis.

METHODS

Retrospective Institutional Review Board approved study. We identified intensive care unit admission diagnosis, laboratory values and vital signs from patient charts. Groups were compared according to admission diagnoses. Data were analysed using descriptive statistics.

RESULTS

We included 91 general intensive care unit admissions among 56,865 deliveries (2011-2015) with complete data. The most common admission diagnosis was postpartum haemorrhage followed by hypertensive diseases of pregnancy and respiratory complications. Women with postpartum haemorrhage had lower mean (standard deviation) platelet counts (120.2 (45.8) vs. 181.2 (109.9), p = .003) and temperatures (35.7 (1.1) vs. 36.5 (1.2), p = .002). Women with hypertensive diseases of pregnancy had higher mean (standard deviation) blood pressures (systolic 150.4 (29.1) vs. 127.4 (21.0), p = .013, diastolic 100.3 (18.7) vs. 76.1 (16.1), p = .001), creatinine (1.1 (0.6) vs. 0.8 (0.3), p = .003), urea (14.6 (7.7) vs. 10.5 (4.7), p = .005) and liver enzymes, including aspartate transaminase (258.4 (297.0) vs. 41.4 (42.9), p = .000), alanine transaminase (184.4 (199.2) vs. 35.1 (75.9), p = .000), and alkaline phosphatase (166.6 (112.6) vs. 96.0 (60.0), p = .006). Women with respiratory complications had lower mean (standard deviation) oxygen saturations (93.7 (6.1) vs. 98.0 (2.6), p = .000), and higher mean (standard deviation) temperatures (37.1 (0.8) vs. 36.0 (1.2), p = .001).

CONCLUSIONS

We report differences in laboratory values and vital signs, according to intensive care unit admission diagnosis. Recognising these differences might help individualise patient assessment and care.

Quick Sequential Organ Failure Assessment: Modifications for Identifying Maternal Morbidity and Mortality in Obstetrical Patients

OBJECTIVE

Screening tools, including the Systemic Inflammatory Response Syndrome (SIRS) criteria and Sequential Organ Failure Assessment (SOFA) criteria, have not been validated in the pregnant population. We aimed to determine if pregnancy-specific modifications to the quick SOFA (qSOFA) can improve prediction of severe maternal morbidity in pregnant women with serious infections.

STUDY DESIGN

We performed a retrospective cohort study of pregnant patients with severe infections admitted to a single institution from January 1, 2011, through December 31, 2017. The primary outcome was severe maternal morbidity, defined as a composite of adverse maternal outcomes: intensive care unit (ICU) admission for >48 hours, need for invasive monitoring (central line or arterial line), intubation, pharmacologic hemodynamic support (intravenous vasopressors or inotropes), and/or maternal death. A logistic regression was then applied and the resulting predictors were analyzed individually and in combination with receiver operating characteristic (ROC) curves to modify qSOFA for pregnancy, that is, qSOFA-P.

RESULTS

Analysis of 104 pregnant patients with severe infections found that the standard qSOFA did not accurately predict severe maternal morbidity (ROC area under the curve [AUC] = 0.54, p = 0.49, sensitivity = 0.38, and specificity = 0.70). Pregnancy-specific modifications or "qSOFA-P" (respiratory rate [RR] ≥ 35 breaths/minute and systolic blood pressure [SBP] ≤ 85 mm Hg) significantly improved prediction of severe maternal morbidity (AUC = 0.77, p < 0.001, sensitivity = 0.79, and specificity = 0.74).

CONCLUSION

The standard qSOFA is a poor screening tool in the prediction of severe maternal morbidity in pregnant patients with infections. A pregnancy-specific screening system, qSOFA-P, improved prediction of severe maternal morbidity in pregnant women with severe infections. Further prospective and large multicenter studies are needed to validate this scoring system in pregnant women.

KEY POINTS

· Validated scoring systems for evaluating pregnant patients with sepsis are needed.. · Modifications to existing systems may improve the evaluation of pregnant patients with sepsis.. · The qSOFA-P (RR ≥ 35 breaths/minute and SBP ≤ 85 mm Hg) includes modifications to qSOFA, and improves the detection of patients who would develop severe maternal morbidity...

Maternal Sepsis: A Review of National and International Guidelines

OBJECTIVE

 Sepsis is a life-threatening syndrome caused by the body's response to infection. The Global Maternal Sepsis Study (GLOSS) suggests sepsis plays a larger role in maternal morbidity and mortality than previously thought. We therefore sought to compare national and international guidelines for maternal sepsis to determine their consistency with each other and the Third International Consensus for Sepsis and Septic Shock (SEPSIS-3).

STUDY DESIGN

 Using Cochrane Database of Systematic Reviews, PubMed, Google Scholar, and organization Web sites, we identified seven guidelines on maternal sepsis in the English language-The American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Society of Obstetric Medicine of Australia and New Zealand, Royal College of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland Institute of Obstetricians and Gynaecologists, and World Health Organization. Guidelines were reviewed to ascertain the commonality and variation, if any, in definitions of maternal sepsis, tools and criteria utilized for diagnosis, obstetric warning systems used, as well as evaluation and management of maternal sepsis. These variables were also compared with SEPSIS-3.

RESULTS

 All guidelines provided definitions consistent with a version of the SEPSIS, although the specific version utilized were varied. Clinical variables and tools employed for diagnosis of maternal sepsis were also varied. Evaluation and management of maternal sepsis and septic shock were similar.

CONCLUSION

 In conclusion, national and international maternal sepsis guidelines were incongruent with each other and SEPSIS-3 in diagnostic criteria and tools but similar in evaluation and management recommendations.

KEY POINTS

· Definitions for maternal sepsis and septic shock are varied.. · Maternal sepsis guidelines differ in proposed criteria and tools.. · Maternal sepsis guidelines have similar management recommendations..

Maternal mortality: near-miss events in middle-income countries, a systematic review

OBJECTIVE

To describe the incidence and main causes of maternal near-miss events in middle-income countries using the World Health Organization's (WHO) maternal near-miss tool and to evaluate its applicability in these settings.

METHODS

We did a systematic review of studies on maternal near misses in middle-income countries published over 2009-2020. We extracted data on number of live births, number of maternal near misses, major causes of maternal near miss and most frequent organ dysfunction. We extracted, or calculated, the maternal near-miss ratio, maternal mortality ratio and mortality index. We also noted descriptions of researchers' experiences and modifications of the WHO tool for local use.

FINDINGS

We included 69 studies from 26 countries (12 lower-middle- and 14 upper-middle-income countries). Studies reported a total of 50 552 maternal near misses out of 10 450 482 live births. Median number of cases of maternal near miss per 1000 live births was 15.9 (interquartile range, IQR: 8.9-34.7) in lower-middle- and 7.8 (IQR: 5.0-9.6) in upper-middle-income countries, with considerable variation between and within countries. The most frequent causes of near miss were obstetric haemorrhage in 19/40 studies in lower-middle-income countries and hypertensive disorders in 15/29 studies in upper-middle-income countries. Around half the studies recommended adaptations to the laboratory and management criteria to avoid underestimation of cases of near miss, as well as clearer guidance to avoid different interpretations of the tool.

CONCLUSION

In several countries, adaptations of the WHO near-miss tool to the local context were suggested, possibly hampering international comparisons, but facilitating locally relevant audits to learn lessons.

Near miss: determinants of maternal near miss and perinatal outcomes: a prospective case control study from a tertiary care center of India

BACKGROUND/PURPOSE

To study the causes of maternal near miss and compared maternal and perinatal outcome of maternal near miss cases with controls (women with potential life-threatening complication [PLTC]) and maternal death.

METHODS

Mothers (n = 100) who fulfilled the WHO criteria for maternal near miss (MNM) were identified and enrolled in the study. Two controls for each near miss case were taken. This included the women who had same PLTC but did not reach near miss within one week of enrollment. The comparison of maternal and fetal outcome was done between the two groups and with the maternal death (MD) group, who presented initially as near miss.

RESULTS

Obstetric hemorrhage was the most common potential life-threatening complication in MNM and MD group. On multiple logistic regression analysis, we found that the presence of organ dysfunction was the independent predictor of near miss and need of mechanical ventilation and coagulation dysfunction as an independent predictor of maternal death. A mother in the near miss group or death group had a higher chance of giving birth to a still-born child (p = < 0.001). Risk of neonatal death after NICU admission was numerically more among near miss and death group than controls, although statistically insignificant (p > .05).

CONCLUSION

Despite making tremendous progress in obstetric care facilities at a tertiary level, developing countries need to strengthen primary care infrastructure and referral system. To improve maternal care, there should be the provision of health education for all pregnant women and antenatal services should be improved.

Human Development Index of the maternal country of origin and its relationship with maternal near miss: A systematic review of the literature

Background

The reduction in maternal mortality worldwide has increased the interest in studying more frequent severe events such as maternal near miss. The Human Development Index is a sociodemographic country-specific variable that includes key human development indicators such as living a long and healthy life, acquiring knowledge, and enjoying a decent standard of living, allowing differentiation between countries. In a globalised environment, it is necessary to study whether the Human Development Index of each patient's country of origin can be associated with the maternal near-miss rate and thus classify the risk of maternal morbidity and mortality.

Methods

A systematic review of the literature published between 2008 and 2019 was conducted, including all articles that reported data about maternal near miss in their sample of pregnant women, in addition to describing the study countries of their sample population. The Human Development Index of the study country, the maternal near-miss rate, the maternal mortality rate, and other maternal-perinatal variables related to morbidity and mortality were used.

Results

After the systematic review, eighty two articles from over thirty countries were included, for a total of 3,699,697 live births, 37,191 near miss cases, and 4029 mortality cases. A statistically significant (p <0.05) inversely proportional relationship was observed between the Human Development Index of the study country and the maternal near-miss and mortality rates. The most common cause of maternal near miss was haemorrhage, with an overall rate of 38.5%, followed by hypertensive disorders of pregnancy (34.2%), sepsis (7.5%), and other undefined causes (20.9%).

Conclusions

The Human Development Index of the maternal country of origin is a sociodemographic variable allowing differentiation and classification of the risk of maternal mortality and near miss in pregnant women. The most common cause of maternal near miss published in the literature was haemorrhage.

Trial registration

PROSPERO ID: CRD 42019133464

Applicability of the WHO maternal near miss tool in sub-Saharan Africa: a systematic review

Background

Applicability of the World Health Organization (WHO) maternal near miss criteria in low-income settings is not systematically addressed in the literature. The objective of this review was to determine the applicability of the WHO maternal near miss tool in sub-Saharan Africa.

Methods

We searched PubMed, Embase, Popline, CINAHL, AJOL, and Google scholar using key words for maternal near miss and sub-Saharan Africa. Studies which applied the WHO maternal near miss criteria, containing clear definitions, and published between January 1st, 2009 and December 31st, 2017 were included. Two authors independently extracted data. Quantitative analysis and narrative synthesis were conducted, and medians with interquartile range (IQR) were calculated for summarizing the findings. Methodological quality of the studies was assessed using the Estabrook’s quality assessment and validity tool.

Results

Fifteen studies from nine countries comprising 227,077 participants were included. Median maternal near miss ratio was 24.2 (IQR: 12.4–35.8) per 1000 live births ranging from 4.4 in a population-based study in South Africa to 198 in a rural private hospital in Nigeria. Eight studies reported challenges in implementing the WHO maternal near miss tool, especially related to the threshold for blood transfusion, and availability of several laboratory-based criteria. In three studies, local adaptations were made.

Conclusion

This review showed that the WHO maternal near miss tool is not uniformly applied in sub-Saharan Africa. Therefore, a common adaptation for the region is required to increase its applicability.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2225-7) contains supplementary material, which is available to authorized users.