Laparotomy in women with severe acute maternal morbidity: secondary analysis of a nationwide cohort study.

BACKGROUND: Although pregnancy-related laparotomy is a major intervention, literature is limited to small case-control or single center studies. We aimed to identify national incidence rates for postpartum laparotomy related to severe acute maternal morbidity (SAMM) in a high-income country and test the hypothesis that risk of postpartum laparotomy differs by mode of birth. METHODS: In a population-based cohort study in all 98 hospitals with a maternity unit in the Netherlands, pregnant women with SAMM according to specified disease and management criteria were included from 01/08/2004 to 01/08/2006. We calculated the incidence of postpartum laparotomy after vaginal and cesarean births. Laparotomies were analyzed in relation to mode of birth using all births in the country as reference. Relative risks (RR) were calculated for laparotomy following emergency and planned cesarean section compared to vaginal birth, excluding laparotomies following births before 24 weeks' gestation and hysterectomies performed during cesarean section. RESULTS: The incidence of postpartum laparotomy in women with SAMM in the Netherlands was 6.0 per 10,000 births. Incidence was 30.1 and 1.8 per 10,000 following cesarean and vaginal birth respectively. Compared to vaginal birth, RR of laparotomy after cesarean birth was 16.7 (95% confidence interval [95% CI] 12.2-22.6). RR was 21.8 (95% CI 15.8-30.2) for emergency and 10.5 (95% CI 7.1-15.6) for planned cesarean section. CONCLUSIONS: Risk of laparotomy, although small, was considerably elevated in women who gave birth by cesarean section. This should be considered in counseling and clinical decision making.

Validating the WHO maternal near miss tool: comparing high- and low-resource settings.

BACKGROUND: WHO proposed the WHO Maternal Near Miss (MNM) tool, classifying women according to several (potentially) life-threatening conditions, to monitor and improve quality of obstetric care. The objective of this study is to analyse merged data of one high- and two low-resource settings where this tool was applied and test whether the tool may be suitable for comparing severe maternal outcome (SMO) between these settings. METHODS: Using three cohort studies that included SMO cases, during two-year time frames in the Netherlands, Tanzania and Malawi we reassessed all SMO cases (as defined by the original studies) with the WHO MNM tool (five disease-, four intervention- and seven organ dysfunction-based criteria). Main outcome measures were prevalence of MNM criteria and case fatality rates (CFR). RESULTS: A total of 3172 women were studied; 2538 (80.0%) from the Netherlands, 248 (7.8%) from Tanzania and 386 (12.2%) from Malawi. Total SMO detection was 2767 (87.2%) for disease-based criteria, 2504 (78.9%) for intervention-based criteria and 1211 (38.2%) for organ dysfunction-based criteria. Including every woman who received ≥1 unit of blood in low-resource settings as life-threatening, as defined by organ dysfunction criteria, led to more equally distributed populations. In one third of all Dutch and Malawian maternal death cases, organ dysfunction criteria could not be identified from medical records. CONCLUSIONS: Applying solely organ dysfunction-based criteria may lead to underreporting of SMO. Therefore, a tool based on defining MNM only upon establishing organ failure is of limited use for comparing settings with varying resources. In low-resource settings, lowering the threshold of transfused units of blood leads to a higher detection rate of MNM. We recommend refined disease-based criteria, accompanied by a limited set of intervention- and organ dysfunction-based criteria to set a measure of severity.

Severe acute maternal morbidity in multiple pregnancies: a nationwide cohort study.

BACKGROUND: Adverse neonatal outcomes in multiple pregnancies have been documented extensively, in particular those associated with the increased risk of preterm birth. Paradoxically, much less is known about adverse maternal events. The combined risk of severe acute maternal morbidity in multiple pregnancies has not been documented previously in any nationwide prospective study. OBJECTIVE: The objective of the study was to assess the risk of severe acute maternal morbidity in multiple pregnancies in a high-income European country and identify possible risk indicators. STUDY DESIGN: In a population-based cohort study including all 98 hospitals with a maternity unit in The Netherlands, pregnant women with severe acute maternal morbidity were included in the period Aug. 1, 2004, until Aug. 1, 2006. We calculated the incidence of severe acute maternal morbidity in multiple pregnancies in The Netherlands using The Netherlands Perinatal Registry. Relative risks (RR) of severe acute maternal morbidity in multiple pregnancies compared with singletons were calculated. To identify possible risk indicators, we also compared age, parity, method of conception, onset of labor, and mode of delivery for multiple pregnancies using The Netherlands Perinatal Registry as reference. RESULTS: A total of 2552 cases of severe acute maternal morbidity were reported during the 2 year study period. Among 202 multiple pregnancies (8.0%), there were 197 twins (7.8%) and 5 triplets (0.2%). The overall incidence of severe acute maternal morbidity was 7.0 per 1000 deliveries and 6.5 and 28.0 per 1000 for singletons and multiple pregnancies, respectively. The relative risk of severe acute maternal morbidity compared with singleton pregnancies was 4.3 (95% confidence interval [CI], 3.7-5.0) and increased to 6.2 (95% CI 2.5-15.3) in triplet pregnancies. Risk indicators for developing severe acute maternal morbidity in women with multiple pregnancies were age of ≥ 40 years, (RR, 2.5 95% CI, 1.4-4.3), nulliparity (RR, 1.8, 95% CI, 1.4-2.4), use of assisted reproductive techniques (RR, 1.9, 95% CI, 1.4-2.5), and nonspontaneous onset of delivery (RR, 1.6, 95% CI, 1.2-2.1). No significant difference was found between mono- and dichorionic twins (RR, 0.8, 95% CI, 0.6-1.2). CONCLUSION: Women with multiple pregnancies in The Netherlands have a more than 4 times elevated risk of sustaining severe acute maternal morbidity as compared with singletons.

Validating the WHO Maternal Near Miss Tool in a high-income country.

INTRODUCTION: This study was performed to assess the applicability of the WHO Maternal Near Miss Tool (MNM Tool) and the organ dysfunction criteria in a high-income country. MATERIAL AND METHODS: The MNM tool was applied to 2552 women who died of pregnancy-related causes or sustained severe acute maternal morbidity between August 2004 and August 2006 in one of the 98 hospitals with a maternity unit in the Netherlands. Fourteen (0.6%) cases had insufficient data for application. Each case was assessed according to the three main "MNM categories" specified in the MNM tool and their subcategory criteria: five disease-, four intervention- and seven organ dysfunction-based criteria. Potentially life-threatening conditions (disease-based inclusions) and life-threatening cases (organ dysfunction-based inclusions) were differentiated according to WHO methodology. Outcomes were incidence of all (sub)categories and case-fatality rates. RESULTS: Of the 2538 cases, 2308 (90.9%) women fulfilled disease-based, 2116 (83.4%) intervention-based and 1024 (40.3%) organ dysfunction-based criteria. Maternal death occurred in 48 women, of whom 23 (47.9%) fulfilled disease-based, 33 (68.8%) intervention-based and 31 (64.6%) organ dysfunction-based criteria. Case-fatality rates were 23/2308 (1.0%) for cases fulfilling the disease-based criteria, 33/2116 (1.6%) for intervention-based criteria and 31/1024 (3.0%) for women fulfilling the organ dysfunction-based criteria. CONCLUSIONS: In the Netherlands, where advanced laboratory and clinical monitoring are available, organ dysfunction-based criteria of the MNM tool failed to identify nearly two-thirds of sustained severe acute maternal morbidity cases and more than one-third of maternal deaths. Disease-based criteria remain important, and using only organ dysfunction-based criteria would lead to underestimating severe acute maternal morbidity.

Overweight and severe acute maternal morbidity in a low-risk pregnant population in the Netherlands.

OBJECTIVE: To investigate the association between overweight and severe acute maternal morbidity (SAMM) in a low-risk pregnant population. DESIGN: Nationwide case-control study. SETTING: The Netherlands, august 2004 to august 2006. POPULATION: 1567 cases from initially primary care and 2994 women from primary care practices as controls, out of 371 012 women delivering in the Netherlands during the study period. METHODS: Cases were women with SAMM obtained from a nationwide prospective study. All women in this cohort who initially had low-risk pregnancies were compared with low-risk women without SAMM to calculate odd ratios (ORs) to develop SAMM by body mass index (BMI) category. We divided body mass index in three overweight categories and calculated the ORs (95% CI) of total SAMM and per specific endpoint by logistic regression, with normal weight as reference. We adjusted for age, parity and socio-economic status. MAIN OUTCOME MEASURES: SAMM, defined as Intensive Care Unit (ICU)-admission, Uterine Rupture, Eclampsia or Major Obstetric Haemorrhage (MOH). RESULTS: SAMM was reported in 1567 cases which started as low-risk pregnancies. BMI was available in 1097 (70.0%) cases and 2994 control subjects were included. Analysis showed a dose response relation for overweight (aOR, 1.3; 95% CI, 1.0-1.5), obese (aOR, 1.4; 95% CI, 1.1-1.9) and morbidly obese (aOR, 2.1; 95% CI, 1.3-3.2) women to develop SAMM compared to normal weight. Sub analysis showed the same dose response relation for ICU-admission, Uterine Rupture and Eclampsia. We found no association for MOH. CONCLUSION: Overweight without pre-existent co-morbidity is an important risk-indicator for developing SAMM. This risk increases with an increasing body mass index.

Puerperal uterine inversion in the Netherlands: a nationwide cohort study.

Puerperal uterine inversion is a severe but rare obstetric complication of yet unknown origin. In this two-year study we determine the incidence of this complication and we describe associated risk factors to expose its etiology. All cases of uterine inversion were included from a nationwide cohort study which contained all 98 hospitals with a maternity unit in the Netherlands. We reviewed the medical records of 15 patients, resulting an incidence of approximately 1 in 20 000 vaginal births. Fourteen cases (93.3%) were classified as low-risk pregnancies at booking. Nulliparous women were not overrepresented and the main associated factors were signs of prolonged labor followed by third stage manipulation. This study is the first population-based study for uterine inversion. With the reported associated factors and occurrence in women with a low-risk profile, we show that every birth attendant should be able to detect this rare but severe complication.