Cases Of Severe Maternal Morbidity Research Articles

Impact of a nationwide study for surveillance of maternal near-miss on the quality of care provided by participating centers: a quantitative and qualitative approach

BackgroundThe Brazilian Network for Surveillance of Severe Maternal Morbidity was established in 27 centers in different regions of Brazil to investigate the frequency of severe maternal morbidity (near-miss and potentially life-threatening conditions) and associated factors, and to create a collaborative network for studies on perinatal health. It also allowed interventions aimed at improving the quality of care in the participating institutions. The objective of this study was to evaluate the perception of the professionals involved regarding the effect of participating in such network on the quality of care provided to women.MethodsA mixed quantitative and qualitative study interviewed coordinators, investigators and managers from all the 27 obstetric units that had participated in the network. Following verbal informed consent, data were collected six and twelve months after the surveillance period using structured and semi-structured interviews that were conducted by telephone and recorded. A descriptive analysis for the quantitative and categorical data, and a thematic content analysis for the answers to the open questions were performed.ResultsThe vast majority (93%) of interviewees considered it was important to have participated in the network and 95% that their ability to identify cases of severe maternal morbidity had improved. They also considered that the study had a positive effect, leading to changes in how cases were identified, better organization/standardization of team activities, changes in routines/protocols, implementation of auditing for severe cases, dissemination of knowledge at local/regional level and a contribution to local and/or national identification of maternal morbidity. After 12 months, interviewees mentioned the need to improve prenatal care and the scientific importance of the results. Some believed that there had been little or no impact due to the poor dissemination of information and the resistance of professionals to change practice. In this second interview, a lack of systematic surveillance after the end of the study, difficulty in referring cases and changes in the leadership of the unit were mentioned.ConclusionIn the opinion of these professionals, participating in a network for the surveillance of severe maternal morbidity represented a good strategy for improving services, even in reference centers.

Severe maternal morbidity and maternal near miss in the extremes of reproductive age: results from a national cross- sectional multicenter study

BackgroundThe aim of this study was to assess severe maternal morbidity (SMM) and near miss (NM) cases among adolescent girls and women over 35 years of age in the Brazilian Network for Surveillance of Severe Maternal Morbidity, using a set of standard criteria, compared to pregnant women aged 20 to 34 years.MethodsA cross-sectional multicenter study conducted in 27 referral obstetric units in Brazil. All pregnant women admitted to these centers during a one-year period of prospective surveillance were screened to identify cases of maternal death (MD), NM and other SMM. Indicators of maternal morbidity and mortality were evaluated for the three age groups. Sociodemographic, clinical and obstetric characteristics, gestational and perinatal outcomes, main causes of morbidity and delays in care were also compared. Two multiple analysis models were performed, to estimate the adjusted prevalence ratio for identified factors that were independently associated with the occurrence of severe maternal outcome (SMO = MNM + MD).ResultsAmong SMM and MD cases identified, the proportion of adolescent girls and older women were 17% each. The risk of MNM or death was 25% higher among older women. Maternal near miss ratio and maternal mortality ratios increased with age, but these ratios were also higher among adolescents aged 10 to 14, although the absolute numbers were low. On multivariate analysis, younger age was not identified as an independent risk factor for SMO, while this was true for older age (PR 1.25; 1.07-1.45).ConclusionsSMO was high among women below 14 years of age and increased with age in Brazilian pregnant women.

Adverse outcomes in maternity care for women with a low risk profile in The Netherlands: a case series analysis.

BackgroundThis study aimed to perform a structural analysis of determinants of risk of critical incidents in care for women with a low risk profile at the start of pregnancy with a view on improving patient safety.MethodsWe included 71 critical incidents in primary midwifery care and subsequent hospital care in case of referral after 36 weeks of pregnancy that were related to substandard care and for that reason were reported to the Health Care Inspectorate in The Netherlands in 36 months (n = 357). We performed a case-by-case analysis, using a previously validated instrument which covered five broad domains: healthcare organization, communication between healthcare providers, patient risk factors, clinical management, and clinical outcomes.ResultsDeterminants that were associated with risk concerned healthcare organization (n = 20 incidents), communication about treatment procedures (n = 39), referral processes (n = 19), risk assessment by telephone triage (n = 10), and clinical management in an out of hours setting (n = 19). The 71 critical incidents included three cases of maternal death, eight cases of severe maternal morbidity, 42 perinatal deaths and 12 critical incidents with severe morbidity for the child. Suboptimal prenatal risk assessment, a delay in availability of health care providers in urgent situations, miscommunication about treatment between care providers, and miscommunication with patients in situations with a language barrier were associated with safety risks.ConclusionsSystematic analysis of critical incidents improves insight in determinants of safety risk. The wide variety of determinants of risk of critical incidents implies that there is no single intervention to improve patient safety in the care for pregnant women with initially a low risk profile.

The epidemiology of life‐threatening complications associated with reproductive process in public hospitals in Argentina

To analyse life-threatening obstetric complications that occurred in public hospitals in Argentina. Multicentre collaborative cross-sectional study. Twenty-five hospitals included in the Perinatal Network of Buenos Aires Metropolitan Area. Women giving birth in participating hospitals during a 1-year period. All cases of severe maternal morbidity (SMM) and maternal mortality (MM) during pregnancy (including miscarriage and induced abortion), labour and puerperium were included. Data were collected prospectively. Identification criteria, main causes and incidence of SMM; case-fatality rates, morbidity-mortality index and effective intervention's use rate. A total of 552 women with life-threatening conditions were identified: 518 with SMM, 34 with MM. Identification criteria for SMM were case-management (48.9%), organ dysfunction (15.2%) and mixed criteria (35.9%). Incidence of SMM was 0.8% (95% confidence interval [95% CI] 0.73-0.87%) and hospital maternal death ratio was 52.3 per 100000 live births (95% CI 35.5-69.1). Main causes of MM were abortion complications and puerperal sepsis; main causes of SMM were postpartum haemorrhage and hypertension. Overall case-fatality rate was 6.2% (95% CI 4.4-8.6): the highest due to sepsis (14.8%) and abortion complications (13.3%). Morbidity-mortality index was 15:1 (95% CI 7.5-30.8). Use rate of known effective interventions to prevent or treat main causes of MM and SMM was 52.3% (95% CI 46.9-57.7). This study describes the importance of life-threatening obstetric complications that took place in public hospitals with comprehensive obstetric care and the low utilisation of known effective interventions that may decrease rates of SMM and MM. It also provides arguments that justify the need to develop a surveillance system for SMM.

Incidence and Predictors of Maternal Cardiovascular Mortality and Severe Morbidity in the Netherlands: A Prospective Cohort Study

ObjectiveTo assess incidence and possible risk factors of severe maternal morbidity and mortality from cardiovascular disease in the Netherlands.DesignA prospective population based cohort study.SettingAll 98 maternity units in the Netherlands.PopulationAll women delivering in the Netherlands between August 2004 and August 2006 (n = 371,021)MethodsCases of severe maternal morbidity and mortality from cardiovascular disease were prospectively collected during a two-year period in the Netherlands. Women with cardiovascular complications during pregnancy or postpartum who were admitted to the ward, intensive care or coronary care unit were included. Cardiovascular morbidity was defined as cardiomyopathy, valvular disease, ischaemic heart disease, arrhythmias or aortic dissection. All women delivering in the same period served as a reference cohort.Main outcome measuresIncidence, case fatality rates and possible risk factors.ResultsIncidence of severe maternal morbidity due to cardiovascular disease was 2.3 per 10,000 deliveries (84/358,874). Maternal mortality rate from cardiovascular disease was 3.0 per 100,000 deliveries (11/358,874). Case fatality rate in women with severe maternal morbidity due to cardiovascular disease was 13% (11/84). Case fatality rate was highest in aortic dissection (83%). Pre-existing acquired or congenital heart disease was identified in 34% of women. Thirty-one percent of women were of advanced maternal age (>35 years of age) and 5 percent above 40 years of age. Possible risk factors for cardiovascular morbidity were caesarean section (either resulting in or as a result of cardiovascular disease), multiple pregnancy, prior caesarean section, non-Western ethnicity and obesity.ConclusionsIn the Netherlands cardiovascular disease is a rare cause of severe maternal morbidity with an incidence of 2.3 per 10,000 deliveries and a high case fatality rate of 13%. Cardiovascular complications develop mostly in women not known with cardiac disease pre-pregnancy.

Severe Maternal Morbidity Among Delivery and Postpartum Hospitalizations in the United States

To propose a new standard for monitoring severe maternal morbidity, update previous estimates of severe maternal morbidity during both delivery and postpartum hospitalizations, and estimate trends in these events in the United States between 1998 and 2009. Delivery and postpartum hospitalizations were identified in the Nationwide Inpatient Sample for the period 1998-2009. International Classification of Diseases, 9 Revision codes indicating severe complications were used to identify hospitalizations with severe maternal morbidity and related in-hospital mortality. Trends were reported using 2-year increments of data. Severe morbidity rates for delivery and postpartum hospitalizations for the 2008-2009 period were 129 and 29, respectively, for every 10,000 delivery hospitalizations. Compared with the 1998-1999 period, severe maternal morbidity increased by 75% and 114% for delivery and postpartum hospitalizations, respectively. We found increasing rates of blood transfusion, acute renal failure, shock, acute myocardial infarction, respiratory distress syndrome, aneurysms, and cardiac surgery during delivery hospitalizations. Moreover, during the study period, rates of postpartum hospitalization with 13 of the 25 severe complications examined more than doubled, and the overall mortality during postpartum hospitalizations increased by 66% (P<.05). Severe maternal morbidity currently affects approximately 52,000 women during their delivery hospitalizations and, based on current trends, this burden is expected to increase. Clinical review of identified cases of severe maternal morbidity can provide an opportunity to identify points of intervention for quality improvement in maternal care. III.

Intraclass correlation coefficients in the Brazilian network for surveillance of severe maternal morbidity study

BackgroundThe purpose of the study was to evaluate intraclass correlation coefficients (ICC) of variables concerning personal characteristics, structure, outcome and process in the Brazilian Network for Surveillance of Severe Maternal Morbidity study conducted to identify severe maternal morbidity/near miss cases using the World Health Organization criteria.MethodIt was a cross-sectional, multicenter study involving 27 hospitals providing care for pregnant women in Brazil. Cluster size and the mean size of the primary sampling unit were described. Estimated prevalence rates, ICC, their respective 95% confidence intervals, the design effect and the mean cluster size were presented for each variable.ResultsOverall, 9,555 cases of severe maternal morbidity (woman admitted with potentially life-threatening conditions, near miss events or death) were included in the study. ICC ranged from < 0.001 to 0.508, with a median of 0.035. ICC was < 0.1 for approximately 75% of the variables. For process-related variables, median ICC was 0.09, with 0.021 for those related to outcome. These findings confirm data from previous studies. Homogeneity may be considered minor, thus increasing reliability of these findings.ConclusionsThese results may be used to design new cluster trials in maternal and perinatal health and to help calculate sample sizes.

Severe maternal morbidity during childbirth hospitalisation: a comparative analysis between the Republic of Ireland and Australia

To determine the population-based rates of severe maternal morbidity during childbirth hospitalisation and associated characteristics in the Republic of Ireland and to directly compare incidence rates with Australia. Retrospective cohort study of 330,955 childbirth hospitalisations between 2005 and 2009. Using validated diagnostic criteria from Australia, we examined hospital discharge records (ICD-10-AM) to identify likely cases of severe maternal morbidity. We derived overall and category-specific morbidity incidence rates and examined five-year trends. Unadjusted relative risks were computed to assess sociodemographic and obstetric factors associated with morbidity status. The severe maternal morbidity five-year incidence rate was 1.34 per 100 deliveries. Between 2005 and 2009, the overall rate of severe morbidity significantly increased from 1.31 to 1.55 cases per 100 deliveries (test for trend p-value <0.001). Similar to Australia, the most frequently diagnosed severe morbidity indicators in Ireland were blood transfusion (112.6 per 10,000 deliveries), evacuation of haematoma (7.2 per 10,000 deliveries) and dilation and curettage with general anaesthesia (3.9 per 10,000 deliveries). In the Irish cohort, the risk of severe morbidity was more than three-fold (RR 3.48; 95% CI: 3.06-3.95) among women carrying multiple gestations and more than four-fold (RR 4.37; 95% CI: 3.66-5.22) among women with a stillbirth. Further, severe morbidity risk was 2.62 times higher among women with a pre-existing medical condition (RR 2.62; CI 2.03-3.37). Our use of low-cost administrative data to identify severe maternal morbidity contributes to a growing body of international initiatives to inform preventive efforts. The ability to directly compare morbidity rates is advantageous, underscoring the need for a uniform definition of severe morbidity to promote accurate and reliable international comparisons.

Severe maternal morbidity in Ireland: what are the rates? what are the risks?

ObjectiveTo derive national rates of severe maternal morbidity diagnosed during hospitalisation for delivery in Ireland.Study DesignRetrospective cohort study of 330,955 women admitted to hospital for delivery between 2005 and 2009....

Applying the new concept of maternal near-miss in an intensive care unit

OBJECTIVES:The World Health Organization has recommended investigating near-misses as a benchmark practice for monitoring maternal healthcare and has standardized the criteria for diagnosis. We aimed to study maternal morbidity and mortality among women admitted to a general intensive care unit during pregnancy or in the postpartum period, using the new World Health Organization criteria.METHODS:In a cross-sectional study, 158 cases of severe maternal morbidity were classified according to their outcomes: death, maternal near-miss, and potentially life-threatening conditions. The health indicators for obstetrical care were calculated. A bivariate analysis was performed using the Chi-square test with Yate's correction or Fisher's exact test. A multiple regression analysis was used to calculate the crude and adjusted odds ratios, together with their respective 95% confidence intervals.RESULTS:Among the 158 admissions, 5 deaths, 43 cases of maternal near-miss, and 110 cases of potentially life-threatening conditions occurred. The near-miss rate was 4.4 cases per 1,000 live births. The near-miss/death ratio was 8.6 near-misses for each maternal death, and the overall mortality index was 10.4%. Hypertensive syndromes were the main cause of admission (67.7% of the cases, 107/158); however, hemorrhage, mainly due to uterine atony and ectopic pregnancy complications, was the main cause of maternal near-misses and deaths (17/43 cases of near-miss and 2/5 deaths).CONCLUSIONS:Hypertension was the main cause of admission and of potentially life-threatening conditions; however, hemorrhage was the main cause of maternal near-misses and deaths at this institution, suggesting that delays may occur in implementing appropriate obstetrical care.

Advance misoprostol distribution to pregnant women for preventing and treating postpartum haemorrhage.

Advance community distribution of misoprostol for preventing or treating postpartum haemorrhage (PPH) has become an attractive strategy to expand uterotonic coverage to places where conventional uterotonic use is not feasible. However, the value and safety of this strategy remain contentious. This is an update of a Cochrane Review first published in 2012. To assess the effectiveness and safety of the strategy of advance misoprostol distribution to pregnant women for the prevention or treatment of PPH in non-facility births. For this update, we searched the Cochrane Pregnancy and Childbirth Trial Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (19 December 2019), and reference lists of retrieved studies. We included randomised, cluster-randomised or quasi-randomised controlled trials of advance misoprostol distribution to pregnant women compared with usual (or standard) care for the prevention or treatment of PPH in non-facility births. We excluded studies without any form of random design and those that were available in abstract form only. At least two review authors independently assessed trials for inclusion, extracted data and assessed the risk of bias in included studies. Two review authors independently assessed the certainty of the evidence using the GRADE approach. Two studies conducted in rural Uganda met the inclusion criteria for this review. One was a stepped-wedge cluster-randomised trial (involving 2466 women) which assessed the effectiveness and safety of misoprostol distribution to pregnant women compared with standard care for PPH prevention during non-facility births. The other study (involving 748 women) was a pilot individually randomised placebo-controlled trial which assessed the logistics and feasibility of community antenatal distribution of misoprostol, as well as the effectiveness and safety of self-administration of misoprostol for PPH prevention. Only 271 (11%) of women in the cluster-randomised trial and 299 (40%) of the women in the individually randomised trial had non-facility births. Data from the two studies could not be meta-analysed as the data available from the stepped-wedge trial were not adjusted for the study design. Therefore, the analysed effects of advance misoprostol distribution on PPH prevention largely reflect the findings of the placebo-controlled trial. Neither of the included studies addressed advance misoprostol distribution for the treatment of PPH. Primary outcomes Severe PPH was not reported in the studies. In both the intervention and standard care arms of the two studies, no cases of severe maternal morbidity or death were recorded among women who had a non-facility birth. Secondary outcomes Compared with standard care, it is uncertain whether advance misoprostol distribution has any effect on blood transfusion (no events, 1 study, 299 women), the number of women not using misoprostol (2% in the advance distribution group versus 4% in the usual care group; risk ratio (RR) 0.50, 95% confidence interval (CI) 0.13 to 1.95, 1 study, 299 women), the number of women not using misoprostol correctly (RR 4.86, 95% CI 0.24 to 100.46, 1 study, 290 women), inappropriate use of misoprostol (RR 4.97, 95% CI 0.24 to 102.59, 1 study, 299 women) or maternal transfer or referral to a health facility (RR 0.66, 95% CI 0.11 to 3.91, 1 study, 299 women). Compared with standard care, it is uncertain whether advance misoprostol provision increases the number of women experiencing minor adverse effects: shivering/chills (RR 1.84, CI 95% 1.35 to 2.50, 1 study, 299 women), fever (RR 1.87, 95% CI 1.16 to 3.00, 1 study, 299 women), or diarrhoea (RR 3.92, 95% CI 0.44 to 34.64, 1 study, 299 women); major adverse effects: placenta retention (RR 1.49, 95% CI 0.25 to 8.79, 1 study, 299 women) or hospital admission for longer than 24 hours (RR 0.99, 95% CI 0.66 to 15.73, 1 study, 299 women) after non-facility birth. For all the outcomes included in the 'Summary of findings' table, we assessed the certainty of the evidence as very low, according to GRADE criteria. Whilst it might be considered reasonable and feasible to provide advance misoprostol to pregnant women where there are no suitable alternative options for the prevention or treatment of PPH, the evidence on the benefits and harms of this approach remains uncertain. Expansion of uterotonic coverage through this strategy should be cautiously implemented either in the context of rigorous research or with targeted monitoring and evaluation of its impact.

SEVERE ACUTE MATERNAL MORBIDITY;

Objective: To determine the frequency and pattern of severe obstetric morbidity and mortality. Design: Cross sectional study.Period: 1st Oct 2005 to 30th Sep 2007. Setting: Military Hospital Rawalpindi. Methods: Cases of severe acute maternal morbidity and maternalmortality were collected and comparisons made of disease profile, organ system dysfunction, parity, mode of delivery, whether incidentoccurred at home or in the hospital and also whether patient was booked or unbooked. Results: One hundred and ten cases of Severe AcuteMaternal Mortality (SAMM) and eleven cases of maternal mortality were identified. More maternal deaths occurred in patients who had notbooked themselves for antenatal care. The four most frequent cases of severe morbidity were: hypertension 36 (32%), haemorrhage 32 (29%),anemia 16 (14%), sepsis12 (10%) in this order. The four causes of deaths were: sepsis 4 (36%), hypertension 4(36%), amniotic fluid embolism2(18.% ), haemorrhage 01(10%). There were statistically significant number of patients in mortality arm of sepsis group (p=0.01) In patients withSAMM there was a higher percentage of patients undergoing caesarean sections in haemorrhage and hypertension arm compared tobackground rate of 35%. Multi organ failure, cerebral and respiratory system involvement was linked to both SAMM and morbidity. Maternalmortality index was highest for sepsis (25%), and lowest for haemorrhage (3%) with hypertension intermediate in position (10%). Conclusions:A review of Severe Acute Maternal Morbidity offers a non threatening stimulus for improving quality of care. Comparison of Severe acutematernal morbidity with maternal death gives a different disease pattern and shows that different factors operate in each condition. Thereforeboth reviews complement each other.

Sequential Organ Failure Assessment Score for Evaluating Organ Failure and Outcome of Severe Maternal Morbidity in Obstetric Intensive Care

Objective. To evaluate the performance of Sequential Organ Failure Assessment (SOFA) score in cases of severe maternal morbidity (SMM). Design. Retrospective study of diagnostic validation. Setting. An obstetric intensive care unit (ICU) in Brazil. Population. 673 women with SMM. Main Outcome Measures. mortality and SOFA score. Methods. Organ failure was evaluated according to maximum score for each one of its six components. The total maximum SOFA score was calculated using the poorest result of each component, reflecting the maximum degree of alteration in systemic organ function. Results. highest total maximum SOFA score was associated with mortality, 12.06 ± 5.47 for women who died and 1.87 ± 2.56 for survivors. There was also a significant correlation between the number of failing organs and maternal mortality, ranging from 0.2% (no failure) to 85.7% (≥3 organs). Analysis of the area under the receiver operating characteristic (ROC) curve (AUC) confirmed the excellent performance of total maximum SOFA score for cases of SMM (AUC = 0.958). Conclusions. Total maximum SOFA score proved to be an effective tool for evaluating severity and estimating prognosis in cases of SMM. Maximum SOFA score may be used to conceptually define and stratify the degree of severity in cases of SMM.

Premature rupture of membranes before 28 weeks managed expectantly: Maternal and perinatal outcomes in a developing country

This study aimed to assess outcomes of expectant management for early preterm premature rupture of membranes (PPROM). This retrospective cohort involved 66 women with PPROM <28 weeks managed in a single hospital (1999–2006). Main outcomes were chorioamnionitis, severe maternal morbidity (maternal sepsis, haemorrhage/blood transfusion, hysterectomy or admission to intensive care unit), maternal mortality, low birth weight, preterm birth, neonatal infection and perinatal mortality. Mean gestational ages at PPROM and delivery were 21.7 ± 4.2 and 28.4 ± 5.9 weeks, respectively. Chorioamnionitis was diagnosed in 47%; no cases of severe maternal morbidity or mortality occurred. Stillbirth rate was 25.7% and >80% of infants were delivered before 34 weeks. Neonatal infection was diagnosed in 42.9% of the 49 live-births. Overall survival rate was 57.6%. Expectant management of PPROM <28 weeks resulted in high rates of chorioamnionitis and preterm deliveries but in over half of the cases, a live infant was discharged home.

P2-464 Incidence and main causes of severe maternal morbidity in SÃo LuÍs/MaranhÃo-Brazil: A Longitudinal Study

IntroductionThe evaluation of severe maternal morbidity has been used in the monitoring of maternal health. The objective of this study is to estimate its incidence and main causes in São...

Developing an assessment tool for maternal morbidity ‘near-miss’- A prospective study in a large Australian regional hospital

Maternal mortality is now a rare event in the developed world and its measurement is no longer a useful way of assessing obstetric care. Examination of cases of women who nearly died but survived a severe complication of pregnancy or childbirth - maternal 'near-misses' - is increasingly being recognised as potentially more useful, although severe maternal morbidity is much less easy to define and quantify than maternal death. To identify and assess prospectively cases of severe maternal morbidity presenting to Cairns Base Hospital (CBH), to define cases as near-misses and thereby develop a tool for future assessment of obstetric care in CBH and elsewhere. Based on approaches recommended by the recent WHO working group on Maternal Mortality and Morbidity classifications, a data collection form was constructed using a combination of named morbidities and specific interventions. Over 1 year data from all cases of severe maternal morbidity was collected and analysed both prospectively and retrospectively to identify true near-misses. Seventeen cases of true near-misses were identified, giving a near-miss rate of six per 1000 live births for CBH in the study period; 64% of cases were attributable to obstetric causes and 36% to non-obstetric causes. Collection of near-miss data has the potential to become a useful tool for the assessment of obstetric care in both in CBH and in other Australian hospitals but is time-consuming and requires continuous surveillance by medical staff if cases are not to be overlooked.

Severe acute maternal morbidity in asylum seekers: a two‐year nationwide cohort study in the Netherlands

Asylum seekers often have poorer physical and mental health compared with the general population. The aim of this study was to assess incidence and risk indicators for severe acute maternal morbidity (SAMM) in asylum seekers. Prospective, population-based cohort study. Setting. All 98 maternity units in the Netherlands. All asylum seekers in the Netherlands. All cases of severe maternal morbidity in asylum seekers were collected during a two-year period. All pregnant women in the Netherlands in the same period acted as a reference cohort (n=371,021). Incidence and possible risk indicators of SAMM in asylum seekers. Of the SAMM cases, 40 were identified as asylum seekers. This yields an incidence of 31 per 1,000 severe maternal morbidity in asylum seekers. Compared with the general Dutch population, asylum seekers have a four- to fivefold increased risk of SAMM (relative risk 4.5; 95% confidence interval 3.3-6.1). Even compared with other non-Western immigrant women, asylum seekers have an increased risk of SAMM (relative risk 3.6; 95% confidence interval 2.6-5.0). Possible risk indicators for SAMM are as follows: a single household, unemployment, low socio-economic status, major language barrier, short stay in the Netherlands, HIV positive, late gestational booking, multiparity and prior cesarean section. Asylum seekers have an increased risk for SAMM compared with other immigrant women, as well as compared with the general Dutch pregnant population. In this study, we identified possible additional risk factors. Special attention is needed while taking care of asylum-seeking pregnant women.

Incidence and main causes of severe maternal morbidity in São Luís, Maranhão, Brazil: a longitudinal study.

Evaluation of severe maternal morbidity has been used in monitoring of maternal health. The objective of this study was to estimate its incidence and main causes in São Luís, Maranhão, Brazil. Prospective longitudinal study, carried out in two public high-risk maternity hospitals and two public intensive care units (ICUs) for referral of obstetric cases from the municipality. Between March 1, 2009, and February 28,2010, all cases of severe maternal morbidity according to the Mantel and Waterstone criteria were identified. The sociodemographic and healthcare characteristics of the extremely severe cases were compared with the less severe cases, using the Fisher, χ(2), Student t and Mann-Whitney tests, with a significance level of < 0.05. 127 cases of severe maternal morbidity were identified among 8,493 deliveries, i.e. an incidence of 15.0/1000 deliveries. Out of 122 cases interviewed, 121 cases were within the Waterstone criteria and 29 were within the Mantel criteria, corresponding to incidences of 14.1/1000 and 3.4/1000 deliveries, respectively. These rates were lower than those described in the literature, possibly due to case loss. The main causes were hypertension during pregnancy, which was more frequent in less severe cases (P = 0.001) and obstetric hemorrhage, which was more common among extremely severe cases (P = 0.01). Direct obstetric disorders were the main causes of severe maternal morbidity in São Luís, Maranhão. Investigation and monitoring of severe morbidity may contribute towards improving obstetric care in the municipality.

Maternal mortality and severe maternal morbidity from acute fatty liver of pregnancy in the Netherlands

Objective To assess maternal death and severe maternal morbidity from acute fatty liver of pregnancy (AFLP) in the Netherlands. Study design A retrospective study of all cases of maternal mortality in the Netherlands between 1983 and 2006 and all cases of severe maternal morbidity in the Netherlands between 2004 and 2006, in which all 98 maternity units in the Netherlands participated. Maternal mortality ratio (MMR) and incidence of severe maternal morbidity were the main outcome measures. Results The MMR from direct maternal mortality from AFLP was 0.13 per 100,000 live births (95% CI 0.05–0.29). The incidence of severe maternal morbidity from AFLP was 3.2 per 100,000 deliveries (95% CI 1.8–5.7). Conclusions AFLP is a rare condition which still causes severe maternal morbidity and in some cases mortality. Referral to a tertiary care hospital for treatment of this uncommon disease should be considered.

Obstetric intensive care unit admission: a 2-year nationwide population-based cohort study

PurposeAs part of a larger nationwide enquiry into severe maternal morbidity, our aim was to assess the incidence and possible risk factors of obstetric intensive care unit (ICU) admission in the Netherlands.MethodsIn a 2-year nationwide prospective population-based cohort study, all ICU admissions during pregnancy, delivery and puerperium (up to 42 days postpartum) were prospectively collected. Incidence, case fatality rate and possible risk factors were assessed, with special attention to the ethnic background of women.ResultsAll 98 Dutch maternity units participated in the study. There were 847 obstetric ICU admissions in 358,874 deliveries, the incidence being 2.4 per 1,000 deliveries. Twenty-nine maternal deaths occurred, resulting in a case fatality rate of 1 in 29 (3.5%). Incidence of ICU admission varied largely across the country. Thirty-three percent of all cases of severe maternal morbidity were admitted to an ICU. Most frequent reasons for ICU admission were major obstetric haemorrhage (48.6%), hypertensive disorders of pregnancy (29.3%) and sepsis (8.1%). Assisted ventilation was needed in 34.8%, inotropic support in 8.8%. In univariable analysis, non-Western immigrant women had a 1.4-fold (95% CI 1.2–1.7) increased risk of ICU admission as compared to Western women. Initial antenatal care by an obstetrician was associated with a higher risk and home delivery with a lower risk of ICU admission.ConclusionsPopulation-based incidence of obstetric ICU admission in the Netherlands was 2.4 per 1,000 deliveries. Obstetric ICU admission accounts for only one-third of all cases of severe maternal morbidity in the Netherlands.