A study on maternal near miss cases in tertiary care center, Chandrapur, Maharashtra, India

Background: Obstetrics near miss is an important indicator that reflects the quality of obstetrics care in a health facility. It assesses and monitors the activities aimed for prevention of maternal mortality. The aim and objective of this study was to find out the incidence, the prevalence and the causes of maternal near miss cases due to severe obstetrics complications.Methods: This is a retrospective study done in department of obstetrics and gynecology in GMC Chandrapur. The study was done during a period from 1st January 2019 to 31st December 2019.Results: In this study the hospital maternal near miss incidence ratio was 13.11%. In this study authors found the most common morbidity was (36.06%) hypertensive disorders of pregnancy, (28.68%) cases of major obstetric haemorrhage, (7.37%) severe systemic infection or sepsis, (2.45%) labour related disorders. In medical disorders very severe anaemia, (13.11%) was most common cause of near miss. The most common cause of death was post-partum haemorrhage (41.66%) and most of the patients referred from periphery in very critical condition.Conclusions: Haemorrhage and hypertension disorders are the leading causes of MNM. Prompt diagnosis and adequate management of near miss cases can reduce mortality rates.

Role of blood transfusion in saving mothers

Background: Blood transfusion is recognised as one of the eight essential components of the comprehensive emergency obstetric care module which has been designed to reduce maternal morbidity and mortality rates after major obstetric hemorrhage and anemia.Methods: This is a prospective observational study conducted between April1, 2016 to September 30, 2018 in department of obstetrics and gynecology, Government Medical College, Patiala. The MNM cases given transfusion were analysed in respect of number of antenatal visits, type of admission, distance of place of first referral unit from tertiary health care facility, amount of blood transfused, indications of blood transfusion, causes of haemorrhage and intervention performed.Results: During this period, there were 123 cases of MNM, 90 patients required blood transfusion and were considered in this study. Maximum number of cases (94.45%) were between 20-35 years of age. Majority of cases were primipara (52.22%). 47.77% cases were in 3rd trimester, 33.33% postnatal cases and 16.66% cases were in first trimester. 88.88% cases requiring transfusion belong to low socioeconomic status. There was no antenatal visit in 80% cases who required blood transfusion. 78.8% patients required more than 4packed red cell transfusions. Haemorrhage was the indication in 60% cases for blood transfusion and anaemia in 40% cases. Postpartum haemorrhage (28.4%) was most common indication for blood transfusion followed by ruptured ectopic pregnancy (27.77%), antepartum haemorrhage (11.11%), rupture uterus (7.4%), rectus sheath hematoma (5.55%), placenta accreta (5.55%) and inversion uterus (3.7%).  Surgical interventions were performed in 51 cases.Conclusions: Prevention and timely treatment of anaemia must receive attention by more active participation in term of antenatal check-ups. Skilled management of patients at the first referral units is advocated. There should be familiarity with the local protocol of relevant members of staff for management of massive hemorrhage. All major hemorrhages should be reviewed to ensure that there is no delay in provision of blood products.

Analysis of transfusion of blood and blood products and their utilization pattern at department of obstetrics of tertiary care hospital

Background: In developing countries, nutritional anaemia and obstetric complications are leading causes of transfusion of blood and blood products. The study was aimed to analyse utilization pattern and to identify the indications of transfusion of blood and blood products in obstetrics and to study outcome and management of pregnancy in patients who required blood and/or blood products.Methods: This retrospective study was carried out at department of obstetrics of tertiary care teaching hospital from September 2018 to November 2018 and data was collected from all patients who had received transfusion of blood and/or blood products for any obstetric cause.Results: A total of 164(6.8%) patients received blood and blood products transfusion. Department of obstetrics utilized maximum units of blood and FFP whereas PRC utilization was second highest. There were 62(37.8%) of patients who had not taken any antenatal care, whereas 64(39.0%) patients had less than 4 antenatal visits. Three most common indications for transfusion of blood and blood products were 63.4% in nutritional anaemia, 17.1% in obstetric haemorrhage and 11.6% in first trimester complications.Conclusions: Three most common indications for transfusion were nutritional anaemia, obstetric haemorrhage and first trimester complications. Majority of patients had inadequate or no antenatal care. Early and regular antenatal care, early diagnosis and management of high-risk pregnancies and obstetric complications, institutional delivery can reduce the rate of transfusion of blood and blood products.

Retrospective review of maternal deaths and maternal near misses due to major obstetric haemorrhage at a tertiary care centre in India

Background: Maternal near miss (MNM) is now widely accepted as a better indicator of maternal health than maternal death and reflects the quality of obstetric care in a particular institution.Methods: This is a retrospective study conducted at Lady Hardinge Medical College and Smt. Sucheta Kriplani  Hospital over a period of 12 months (April 2016-March 2017), of  all cases of maternal death and near miss maternal deaths due to major obstetric haemorrhage(MOH).Results: During the period reviewed, there were 13,083 deliveries, 12,958 live births and 37 maternal deaths. There were 30 cases of near miss maternal deaths and 2 maternal mortalities due to MOH. The mortality index was 6.25%. Severe maternal outcome ratio (SMOR) was  2.46.Among the near miss cases (n=30), morbidly adherent placenta was the cause in 26.6% of cases(n=8), postpartum hemorrhage in 23% of cases(n=7); rupture uterus in 13% cases(n=4); massive abruption in 13% of cases(n=4) and placenta praevia with antepartum haemorrhage in 3% of cases(n=1). Early obstetric haemorrhage due to ruptured ectopic pregnancy and incomplete abortion resulted in MNM in 16% (n=5) and 3.3% (n=1) cases respectively.It was observed that in 40% (n=12) of MNM cases (8 cases of morbidly adherent placenta plus 4 cases of rupture uterus), previous cesarean section was the single most important causative factor  for the morbidity of the patient.Conclusions: Reduction in cesarean section rates is imperative to reduce morbidity and mortality associated with MOH.

Review of maternal mortality in a tertiary care urban teaching hospital: 10 year retrospective study

Background: The objectives of this study were to calculate the maternal mortality ratio, causes for maternal death in our institution and the duration of hospital admission to death interval.Methods: The study included collecting and analyzing the details of maternal death in women who were admitted to St. Johns Medical College Hospital, Bengaluru, from January 2007 to December 2016. Results: Total maternal deaths were 61 and live births were 26,001 during the study period. The maternal mortality ratio (MMR) was 234.6 per 100,000 live births. Majority of maternal deaths occurred in women aged 18 - 35 years 56 (91.80%) women, primipara 45 (73.77%) and referred cases to our institution from other hospitals 52 (85.24%).                      Most of the women died in the postnatal period 54 (88.52%). Direct obstetric causes accounted for 44 (72.13%) maternal deaths and indirect causes 17 (27.86%) deaths. Preeclampsia and eclampsia were the leading causes for death 13 (21.31%) followed by acute fatty liver of pregnancy 12 (19.67%), hemorrhage 7 (13.11%) and sepsis 6 (9.83%). Anemia was present in 77.04% of women at the time of admission to our hospital. Thirty six (59.01%) women died within a week of admission to the hospital, in which 13 (21.31%) women died in less than 24hours of admission. Twenty five (40.98%) women died after a week of admission to hospital.Conclusions: Apart from the triad of preeclampsia, obstetric haemorrhage and sepsis, acute fatty liver of pregnancy has emerged as an important cause of maternal death. Most of the maternal deaths are preventable. Early detection of complications and timely referral to tertiary care hospital in St. Johns Medical College Hospital, Bengaluru, Karnataka, India decreases maternal morbidity and mortality.

Pacientes con morbilidad obstétrica grave de acuerdo con la Organización Mundial de la Salud, atendidas en un hospital de alta especialidad (2010-2016) / Patients with severe obstetric morbidity, according to the World Health Organization, atended at the high specialty hospital (2010 to 2016)

Resumen OBJETIVO: Estimar la morbilidad obstétrica grave y mortalidad materna en el Hospital Juárez de México. MATERIALES Y MÉTODOS: Estudio retrospectivo y transversal efectuado para evaluar los registros de pacientes con morbilidad obstétrica grave y la mortalidad materna, de acuerdo con los criterios de la OMS, atendidas en el Hospital Juárez de México de 2010-2016. Se analizaron las variables relacionadas con el diagnóstico, insuficiencia o disfunción orgánica y las intervenciones asociadas con el tratamiento. Se calculó la tasa de morbilidad materna extrema y obstétrica grave (Near Miss/total de embarazadas). Se utilizaron medidas de tendencia central y de dispersión. RESULTADOS: Se registraron 137 casos de morbilidad obstétrica grave y 26 de muerte materna. La mortalidad promedio fue de 5.78% y el índice de mortalidad de 0.415. Las principales causas de morbilidad materna grave y mortalidad fueron: hemorragia obstétrica, hipertensión asociada con el embarazo y sepsis. Se observó un incremento en los casos de morbilidad materna grave y disminución de la mortalidad materna en el periodo estudiado. CONCLUSIÓN: Se sugiere establecer un comité de evaluación y análisis de pacientes con morbilidad obstétrica grave para mejorar la calidad de atención y tratamiento, y disminuir la tasa de mortalidad materna.

Abstract OBJECTIVE: To determine how many cases of severe obstetric morbidity and maternal mortality were presented in 2010-2016, at the Hospital Juárez de México. MATERIALS AND METHODS: A retrospective, cross-sectional, observational study was carried out in cases of severe obstetric morbidity and maternal death were included according, to WHO criteria, attended in the Hospital Juárez de México from 2010-2016,. We included variables related to the diagnosis, with the organic failure or dysfunction and the interventions related to the management. The extreme maternal morbidity rate was calculated; obstetric (Near miss / Total pregnant). Measures of central tendency and dispersion were used. RESULTS: A total of 137 cases of severe obstetric morbidity and 26 of maternal deaths were registered. The mortality rate on average was 5.78% and death rate .415. The main causes of severe maternal morbidity and mortality were obstetric haemorrhage, hypertension associated with pregnancy and sepsis. There was an increase in cases of severe maternal morbidity and decrease in maternal death in the period studied. CONCLUSION: We suggest the establishment of a committee to evaluate and analyze cases of severe obstetric morbidity to improve the quality of care and treatment for this group of pregnant women, to reduce maternal death.

Use of Recombinant Factor VIIa in Obstetrics.

The objective of this review article was to evaluate the current literature on the increasing off-label use of rFVIIa in the management of critical obstetric haemorrhage. Given the lack of high-level evidence, there is a need to review the clinical indications, observed response and adverse events. This review is designed to aid practitioners in deciding when and how to administer rFVIIa; since the current evidence from observational studies shows that benefits outweigh risks in its use as an adjunct to conventional treatment in massive haemorrhage. However, pregnancy is a potentially thrombogenic state, hence a cautious approach is required in patients with risk factors for thromboembolic complications.

Eficacia y seguridad del taponamiento uterino para control de hemorragia y disminución de histerectomía obstétrica: cohorte histórica en Nuevo León, México, 2013 / Efficacy and safety of uterine tamponade to control bleeding and reduce obstetric hysterectomy: historic cohort in Nuevo León, México, 2013

Objetivo: realizar una aproximación a la eficacia y seguridad del taponamiento uterino para el control de la hemorragia obstétrica y reducir la necesidad de histerectomía obstétrica.Materiales y métodos: cohorte histórica de mujeres mayores de edad con diagnóstico de hemorragia obstétrica secundaria a atonía que no respondían a manejo inicial, con sangrado del lecho placentario secundario a placentación anormal o secundaria a aborto incompleto, a las cuales se les realizó taponamiento uterino, en la Unidad Médica de Alta Especialidad No. 23 de Ginecología y Obstetricia de la ciudad de Monterrey, hospital de concentración de tercer nivel de atención, ubicado en el estado de Nuevo León (México), de enero a diciembre de 2013. A partir del expediente clínico se registraron las características sociodemográficas y clínicas basales, los datos de laboratorio previo al evento obstétrico y posterior al taponamiento, así como el tiempo de taponamiento en horas, cantidad de insuflación del balón uterino, indicación para el procedimiento, cantidad de sangrado estimado durante el evento obstétrico y posterior a la colocación del balón, control de la hemorragia y necesidad de histerectomía. Se utilizó estadística descriptiva, medidas de dispersión y de tendencia central.Resultados: se incluyeron 161 pacientes con diagnóstico de hemorragia obstétrica, 147 posterior a parto o cesárea y 14 posterior al aborto, entre 16 y 42 años de edad. Se documentó un resultado satisfactorio en más del 95 % posterior al parto o la cesárea, y en más del 93 % posaborto. La permanencia del taponamiento para ambos casos tuvo una media de 20 horas.Conclusiones: este estudio soporta el uso de taponamiento uterino como medida terapéutica eficaz y segura para controlar la hemorragia y evitar una laparotomía o histerectomía, con una disminución de la morbilidad.

Objective: Examine the efficacy and safety of uterine tamponade for controlling obstetric bleeding and reducing the need for obstetric hysterectomy.Materials and methods: Historic cohort of adult women diagnosed with obstetric bleeding secondary to uterine atony that did not respond to the initial management, with bleeding of the placental bed secondary to abnormal placentation or to incomplete abortion, subjected to uterine tamponade at the Highly Specialized Gynaecology and Obstetrics Medical Unit No. 23, a Level III Hospital in the city of Monterrey, state of Nuevo Leon, Mexico, between January and December 2013. Information about social, demographic and baseline clinical characteristics, laboratory values before the obstetric event and after the tamponade procedure, as well as the inflation volume of the balloon, the indication of the procedure, the estimated amount of bleeding during the event and after placement of the tamponade balloon, control of bleeding, and need for hysterectomy, was derived from the clinical record. Descriptive statistics, scatter measurements, and central trends were used.Results: Overall, 161 patients between the ages of 16 and 42 years, with a diagnosis of obstetric haemorrhage were included, 147 following delivery or caesarean section, and 14 following miscarriage. A satisfactory result was documented in more than 95 % of cases after delivery or caesarean section, and in more than 93 % post abortion cases. The mean tamponade time for both groups was 20 hours.Conclusions: This study supports the use of uterine tamponade as an effective and safe therapeutic measure to control bleeding and avoid laparotomy or hysterectomy, and to reduce morbidity.

Implementation of an obstetric cell salvage service in a tertiary women's hospital

<p><b>INTRODUCTION</b>Intraoperative cell salvage (ICS) is an important aspect of patient blood management programmes. An ICS service was introduced at KK Women's and Children's Hospital, Singapore, from 2 May 2011 to 30 April 2013 to aid in the management of massive obstetric haemorrhage.</p><p><b>METHODS</b>With support from the Ministry of Health's Healthcare Quality Improvement and Innovation Fund, a workgroup comprising obstetricians, anaesthetists and nursing staff was formed to develop training requirements, clinical guidelines and protocols for implementing ICS using the Haemonetics Cell Saver 5. Pregnant women with an anticipated blood loss of > 1,000 mL during Caesarean delivery, a baseline haemoglobin level of < 10 g/dL, rare blood types and who had refused donor blood were recruited to the service after obtaining informed consent.</p><p><b>RESULTS</b>A total of 11 women were recruited to the ICS service; the primary indications were placenta praevia and placenta accreta. Median blood loss in these 11 patients was 1,500 (range 400-3,000) mL. In four patients, adequate autologous blood was collected to initiate processing and salvaged, processed blood was successfully reinfused (mean 381.3 [range 223.0-700.0] mL). Median blood loss among these four patients was 2,000 (range 2,000-3,000) mL. No adverse event occurred following autologous transfusion. Mean immediate postoperative haemoglobin level was 8.0 (range 7.1-9.4) g/dL.</p><p><b>CONCLUSION</b>The implementation of an obstetric ICS service in our institution was successful. Future studies should seek to address the cost-effectiveness of ICS in reducing allogeneic blood utilisation.</p>