STUDY OF MATERNAL NEAR MISS CASES
IN A TERTIARY CARE HOSPITAL
A Dissertation Submitted to
THE TAMILNADU DR. M.G.R MEDICAL UNIVERSITY
CHENNAI
In Partial fulfilments of the Regulations
for the Award of the Degree of
M.S. (OBSTETRICS & GYNAECOLOGY) BRANCH – II
GOVERNMENT STANLEY MEDICAL COLLEGE
CHENNAI
CERTIFICATE BY THE INSTITUTION
This is to certify that dissertation entitled “STUDY OF
MATERNAL NEAR MISS CASES IN A TERTIARY CARE HOSPITAL” is a bonafide work done by Dr. T. M. VAISHNAVI at R.S.R.M Lying in Hospital, Stanley Medical College, and Chennai. This
dissertation is submitted to TamilnaduDr.M.G.R. Medical University in
partial fulfilment of university rules and regulations for the award of
M.S. Degree in Obstetrics and Gynaecology.
Prof.Dr. PONNAMBALA NAMASIVAYAM, M.D., D.A., DNB.,
Dean,
Government Stanley Medical College & Hospital,
Chennai – 01.
Dr. K. KALAIVANI, M.D., D.G.O., DNB.
Prof & Head of Department, Dept. of Obstetrics and Gynecology Government RSRM Lying In Hospital, Stanley Medical College,
CERTIFICATE BY THE GUIDE
This is to certify that this dissertation entitled “STUDY OF
MATERNAL NEAR MISS CASES IN A TERTIARY CARE HOSPITAL” submitted by Dr. T. M. Vaishnavi, appearing for Part II MS, Branch II Obstetrics and Gynaecology Degree Examination in April
2018, is a Bonafide record of work done by her, under my direct
guidance and supervision as per the rules and regulations of the Tamil
Nadu Dr. MGR Medical University, Chennai, Tamil Nadu, India.
I forward this dissertation to the Tamil Nadu Dr. MGR Medical
University Chennai, India.
Prof.Dr. C. SUMATHI., M.D., D.G.O.,
Professor,
Dept. of Obstetrics and Gynecology Government RSRM Lying In Hospital,
DECLARATION
I,Dr.T.M.VAISHNAVI, solemnly declare that the
dissertation titled,
“STUDY OF MATERNAL NEAR
MISS CASES IN A TERTIARY CARE HOSPITAL”
is
a bonafide work done by me at R.S.R.M. Lying in Hospital,
Stanley Medical College, Chennai during January 2016 to June
2017 under the guidance and supervision of
Prof.Dr.K. Kalaivani M.D., D.G.O.,DNB., Professor and Head
of the department, Obstetrics and Gynaecology. The dissertation
is submitted to the Tamilnadu Dr. M.G.R. Medical University, in
partial fulfilment of University rules and regulations for the
award of M.S. Degree in obstetrics and Gynaecology.
Dr. T. M. Vaishnavi
Date:
ACKNOWLEDGMENT
I am grateful to Prof.Dr.PONNAMBALA NAMASIVAYAM,
M.D., D.A., DNB, Dean, Govt. Stanley Medical College forgranting me permission to undertake this study.
I take this opportunity to express my sincere and humble
gratitude to Dr. K. KALAIVANI, M.D., D.G.O., DNB.,
Superintendent, Govt. R.S.R.M. Lying in Hospital who not only
gave me the opportunity and necessary facilities to carry out
this work but also gave me encouragement and invaluable
guidance to complete the task I had undertaken.
I am deeply indebted to Prof.Dr. C. SUMATHI., M.D.,
D.G.O. the mover behind this study for her able guidance and
inspiration and constant support without which this would not
have been possible.
during this study.
I am extremely grateful to all our Assistant Professors, for
their advice and support during this study. I sincerely thank my
fellow postgraduates and friends for their support and
cooperation.
I owe a great many thanks to all my patients without whom
this study would not have been possible.
This is to certify that this dissertation work titled STUDY OF
MATERNAL NEAR MISS CASES IN A TERTIARY CARE
HOSPITAL of the candidate Dr. T.M. VAISHNAVI with registration
Number 221516058 for the award of MASTER OF SURGERY in the
branch of OBSTETRICS AND GYNAECOLOGY.
I personally verified the urkund.com website for the purpose of
plagiarism Check. I found that the uploaded thesis file contains from
introduction to conclusion pages and result shows 0 percentage of
plagiarism in the dissertation.
CONTENTS
S.NO TITLE PAGE NO
1. INTRODUCTION 1
2. REVIEW OF LITERATURE 4
3. AIM OF THE STUDY 44
4. MATERIALS AND METHODS 45
5. STATISTICAL ANALYSIS 47
6. DISCUSSION 64
7. SUMMARY 70
8. CONCLUSION 74
9. BIBLIOGRAPHY
10. ANNEXURES
PROFORMA
MASTER CHART
ABBREVIATIONS
CONSENT FORM
ETHICAL COMMITTEE APPROVAL
INTRODUCTION
Medicine is a field of ever changing science, and so is obstetrics.
A woman, when pregnant undergoes infinite changes,
physiologically and sometimes even pathologically. The importance of
obstetrics is reflected by the use of maternal and neonatal outcomes as an
index of the quality of health and life among nations. Severe pathological
and circumstantial factors are shared by women who develop severe
acute pregnancy complications.
In Millennium development goal 2000, the goal number 5 was to
improve the maternal health. It is falling way below our target, as our aim
to reduce the maternal mortality by 75 % by 2015 has not been met.
Evaluation of obstetrics cases with severe outcomes gives us much
information about the processes that set in the events of maternal
morbidity and mortality.
2
As maternal deaths have become so uncommon, the practice of
analysing Severe Acute Maternal Morbidity (SAMM) has evolved, to improve obstetrics and perinatal care.
Because avoidance of medical errors serves to decrease the rate of
maternal mortality or severe maternal morbidity, the concept of near miss
or close calls have been introduced.
The advantages of investigating near miss events are:
1. The number of cases are more than maternal deaths hence
more data is available.
2. Causes of MATERNAL NEAR MISS and MMR are the same, so
more information can be obtained by auditing MATERNAL
NEAR MISS because of availability of large amount of data.
3. They are less threatening to the health care providers because
the woman survived.
4. Since the woman survived, interviewing the woman can give
Considering the importance of the factors revolving around the
causes of maternal morbidity and mortality, this study aims at identifying
4
REVIEW OF LITERATURE
Maternal near miss is defined as “A woman who nearly died but
survived a complication that occurred during childbirth or within 42 days
of termination of pregnancy“. (WHO)
The millennium development goals place health at the heart of
development and represent commitments by governments of several
countries throughout the world to do more to reduce poverty and hunger,
and to tackle ill-health, gender inequality, lack of education, access to
clean water and environmental degradation. 3 of the 8 goals are directly
health related and all of the other goals have important indirect effects on
health. (H. S. Neilsen)
In the millennium development goal 2000, goal number 5 is to
improve maternal health. Our target to reduce maternal mortality by 75%
has not been achieved.
The term “near miss morbidity” was first coined by Stones et al,
followed by which several systems for analysing maternal morbidity
were devised in various nations across the world.
Such a system to assess maternal and perinatal outcome has been
system, Australia and New Zealand. The Australian Maternity Outcome
Surveillance System- AMOSS (Haliday, 2013).
In a study conducted in USA in 1998 to 2009 with records from the
Nationwide inpatient sample (Callaghan,2012), 50 million maternity
records were analysed. These investigations reported that 12 per 10000 of
nearly 50 million pregnant women had at least one indicator of severe
morbidity.
In a study conducted in India(2007 to 2008), SAMM was found to
be 7.1% and case fatality ratio 13.8%. SAMM incidence was found to be
0.07% to 8.2%. (Prakash Prabakar Rao Doke)
During January 2007 to December 2010, women were examined
during first week postpartum. In the study 7.4% had severe anemia, 46%
had moderate anemia, 4% had fever, 4.9% had breast conditions, and
4.5% had perineal conditions. Higher morbidities were found in women
who delivered at home. Overall 67.6% of women have some
complication or the other. On follow up, 4.8% of women had depressive
disorder. (Prakash Prabhakar rao doke). 1.4 million Women in the world
experience acute obstetric morbidity (near miss) events. 9.5 million
6
According to WHO estimate in 2008, 42% of pregnant women
have anemia. Severe obstetric haemorrhage, hypertensive disorders of
pregnancy and sepsis are the other common near miss conditions. In the
DLHS-3, 2007 to 2008, haemorrhage and sepsis were found to be the
most common cause of maternal morbidity. Bihar had the highest portion
of maternal morbidity with a percentage of 75.4 %. (DLHS – 3,
2007-2008).
According to a study done at Chhattisgarh, India in September
2013 to August 2014, 41.02% of the cases in the near miss group were of
the age 18 to 24. More number of multipara was in the group.
Haemorrhage- (43.5%)was the major cause of morbidity, followed by
severe anemia (15.8%).Pre- eclampsia (31.57%) was the most common
cause of maternal mortality, followed by sepsis (15.78%) and by severe
anemia. (Bansal M)
In the Department Of Obstetrics And Gynaecology, Kasturba
Hospital, Manipal University, a study of near miss obstetric events and
maternal deaths was done and the ratio was found to be 17.8/ 1000 live
births. Haemorrhage was the leading cause(44.2%) followed by
hypertensive disorder (23.6%) and sepsis (16.3%). Primiparas were more
WHO NEAR-MISS APPROACH FOR MATERNAL HEALTH:
It is guided for evaluating maternal near miss cases. It is used by
health care workers, programme managers and policy makers who are
held responsible for the quality of health care at their level. It is
systematic process for assessing the quality of health care.
It consists of 3 steps implemented in a cyclical manner:
1. Base line assessment or reassessment
2. Situation analysis
3. Interventions for improving health care.
Data for assessment of these cases are collected from records of the
patients. These data collected based on the occurrence of life threatening
events to the patients. This data provides results regarding local rates and
patterns of maternal mortality and morbidity, strength and weakness in
the referral system and the clinical and health care intervention. The
findings of the assessment should be made public since this information
has a value for promoting policy actions and mobilising professional and
8
Since the millennium development goal is failing WHO
recommended that all deliveries be conducted by a skilled worker and
hence effective interventions can be made at the need of time.
But due to lack of financial resources and skilled health care
workers in many low and middle income countries, such policies may
lead to overloading of health care facilities. This could have serious
implications for health care quality. A plan that aims at reducing delays
in the provision of effective care for all pregnant women is a feasible and
cost effective approach.
To make sure that the evaluation of quality of health care with a
near-miss approach is comprehensive, a set of process indicators has been
developed. The near miss approach has been suggested for routine use in
national programmes in order to improve maternal care and prevent
maternal morbidity and mortality.
Definition of terms:
1. Severe maternal complications:
These are potentially life threatening conditions during pregnancy, during
The following are the 5 potential life threatening conditions:
1. Severe preeclampsia
2. Eclampsia
3. Severe postpartum hemorrhage
4. Sepsis/severe systemic infections
5. Rupture uterus.
2. Critical interventions:
Interventions that are required to manage severe maternal
complications like,
(A) blood transfusions
(B) Interventional radiology
(C) laparotomy- hysterectomy and emergency surgical intervention in
10
3. Maternal Death:
Maternal death is defined as death of a woman while pregnant or
within 42 days of termination of pregnancy irrespective of the duration
and site of pregnancy, from any cause related to aggravated by the
pregnancy or its management, but not from accidental or incidental
causes” (WHO 1993).
4. Maternal near miss(MNM)
A maternal near miss case is defined as “a women who nearly died
but survived a complication that occurred during pregnancy, child birth
or within 42 days of termination of pregnancy” (Say et al, 2004; WHO
2009)
5. Process indicators:
Process indicators assess the use of key interventions for the
prevention and management of severe complications.
6. Sentinel units:
Structures in the facility that are likely to provide care for women
The following are the maternal near miss indicators:
1. Maternal near miss(MNM)
2. Maternal death(MD)
3. Live birth(LB)
4. Severe maternal outcome
5. Women with life threatening conditions
6. Severe maternal outcome ratio
7. MNM ratio(MNMR=MNM/LB)
8. Maternal near miss mortality ratio
12
MATERNAL NEAR MISS OPERATIONAL GUIDELINES
The clinical findings, investigations and interventions have been
put under three broad categories;
1) Pregnancy specific obstetric and medical disorders,
2) Pre-existing disorders aggravated during pregnancy,
3) Accidental / Incidental disorders in pregnancy.
These broader categories have further been segregated under
PREGNANCY SPECIFIC CAUSES OF NEAR MISS:
1. OBSTERTIC HEMORRHAGE:
Obstetric haemorrhage along with hypertension and infection
continues as the most common ‘infamous triad’ of maternal deaths in
both developed and underdeveloped countries. It is a leading reason for
admission of women into ICU’s. (Grozier 2011; small 2012,zwart 2008).
Decrease in maternal mortality rate during the 20th century has
been mainly attributed to a decrease in maternal haemorrhage. (Hoyert
2007).
(i) POST PARTUM HAEMORRHAGE:
Post partum haemorrhage is defined as, “loss of 500 ml or more
blood from the genital tract after the completion of third stage of labour”.
In general, an estimated loss more than average or 500 ml ofblood
must always alert the obstetrician.
Uterine atony with bleeding from placental implantation site,
genital tract trauma or both is the frequent causes of post partum
24
(ii) LATE POST PARTUM HAEMORRHAGE:
Bleeding after the first 24 hours is called late postpartum
haemorrhage. It is found to be in 1% of women and may be serious
(ACOG, 2013)
Causes of postpartum haemorrhage:
Uterine atony
Uterine inversion
Injuries to the birth canal
Puerperal hematomas
Rupture of uterus
ANTE PARTUM HAEMORRHAGE
(iii) ABRUPTIO PLACENTA:
Abruptio Placenta is the separation of placenta from site of
attachment before delivery. Maternal morbidity and mortality in abruptio
placenta is due to hypovolemic shock, DIC and renal failure. Timely
(iv) PLACENTA PREVIA:
Attachment of placenta in lower uterine segment either over or
very n ear the internal cervical os. Due to lack of myometrial fibres aiding
in the contraction of the lower uterine segment after delivery of the
foetus, placenta previa results in massive blood loss, hence hypovolemic
shock and hence further morbidity.
Among the causes of obstetric haemorrhage uterine atonicity and
placental abruption are the major contributors to maternal mortality
followed by DIC, traumatic post partum haemorrhage, placenta accreta
and retained placenta. (Al-zirqi et al, 2008)
(v) HYPERTENSIVE DISORDERS OF PREGNANCY (PREGNANCY
INDUCED HYPERTENSION, PREECLAMPSIA, ECLAMPISA):
Hypertension is a leading cause of maternal and perinatal
mortality. Incidence varies from 5-10% and it is still rising. (Lojo, 2013).
In other hand with better management of preeclampsia and better
26
The National Institute of Health (NIH)(Working Group of the
NHBPEP, 2000) categorised hypertensive disorders of pregnancy into
4 types:
1. Gestational hypertension
2. Preeclampsia and eclampsia
3. Preeclampsia super imposed on chronic hypertension
4. Chronic hypertension
Hypertension is a multisystem disease involving the
Cardiovascular System, Haematological System, Renal System,
Hepatobiliary System, and Central Nervous System.
Primigravida, multiple pregnancy, advanced maternal age, inter
pregnancy interval of more than 10 years, booking blood pressure more
than or equal to 130/80 are the markers that help screening of mothers
with high risk of pre eclampsia.(Magee LA, Heleva M et al. 2008 Mar).
The basic management goals for women with preeclampsia are
1. Termination of pregnancy with the least possible trauma to mother
2. A subsequently well baby
3. Complete restoration of health to mother.
All the above three objectives are served well with women who are
term or near term by induction of labour. Adequate knowledge about the
gestational age of fetus is necessary for the achievement of these goals.
The management depends on
1. Preeclampsia severity
2. Gestational age
3. Condition of the cervix.
Treatment options for preeclampsia include pharmacological
agents, dietary supplementation and lifestyle modification. Primary goal
in the management of preeclampsia is prolonging the pregnancy as much
as possible to achieve foetal maturity with proper blood pressure control.
HELLP isa much known complication of severe preeclampsia. It
occurs in 0.2 to 0.6 % of all pregnancies and 10-20% cases with severe
28
Women with HELLP syndrome may have an increased risk of
developing some form of gestational hypertension in subsequent
pregnancy. HELLP is characterised by hemolysis, elevated liver
enzymes, low platelet count.
Eclampsia complicates 1 in 100 to 1 in 1700 cases in developing
countries. (Duckitt K, et. Al., 2005).Eclampsia is most common in the
third trimester and becomes even more frequent when term approaches.
This is probably related to improved access to care, early detection and
prophylactic use of magnesium sulphate(Chames MC et al, 2002). Other
diagnosis should also be considered in women with eclampsia especially
when they present 48 hours postpartum, women who had prior
neurological deficits, prolonged come, or atypical eclampsia)
SEPTIC ABORTIONS:
1 to 2% of women with incomplete or threatened miscarriage
develop a sepsis syndrome or a pelvic infection. Planned surgical or
medical abortions may also lead to fatal and lethal infections. (Barrett,
At the time of induced abortion or spontaneous abortion that
requires medical or surgical intervention; prophylactic antibiotics are
given to prevent post abortal sepsis. (ACOG 2011b).
The main objectives to the treatment of septic abortion are:
1. Removal of infected products of conception
2. Intra-venous administration of broad spectrum antibiotics
Uterine evacuation should be planned 6-12 hours after the
administration of antibiotics to prevent disseminating infection. Persistent
rigors and tachycardia are signs of disseminated infections. Failure of
response within 36-48 hours suggests the presence of alternative
diagnosis like uterine perforation, pelvic abscess especially in criminally
induced cases. In such cases surgical intervention with laparotomy or
hysterectomy are warranted.
(vi) PUERPERAL SEPSIS:
Filker and Monif reported that only about 20% of women febrile
within the first 24 hours of giving birth vaginally were diagnosed to have
pelvic infection. On the contrary, 70% of the women who underwent a
30
Non severe metritis needs treatment with oral antibiotics. Moderate
to severe infections need intravenous therapy with broad spectrum
antibiotics. There is improvement within 48 to 72 hours. Untreated
puerperal infection may lead to phlegmons or abscesses and septic pelvic
thrombophlebitis (Jaiyeoba, 2012).
(vii) UTERINE INVERSION:
Uterine inversion is defined as the passage of the uterine fundus
through the endometrial cavity and cervix, turning the uterus inside out.
Depending on the contributing factors the incidence and severity of
uterine inversion varies. The worst scenario being, complete inversion of
uterus, protruding through the birth canal. Incidences range from 1:2000
to 1:20000 deliveries. ( Baskett, 2002; Ogah, 2011; Rana 2009).
Many of these inversions present as a life threatening haemorrhage,
which may require blood replacements.
(viii) PERIPARTUM CARDIOMYOPATHY:
Peripartum cardiomyopathy is a form of dilated cardiomyopathy
seen in previously healthy women, anytime during pregnancy or
postpartum. Incidence varies from 1 in 3000 to 1 in 4000 patients.
Maternal mortality has decreased to 2-3% in the recent years due to
better management of cardiac failure. (Capriola M, 2013).
(ix) ECTOPIC PREGNANCY:
Ectopic pregnancy is when the zygote gets implanted anywhere
other than the uterine cavity. 95% of the ectopic pregnancies get
implanted in the various parts of the fallopian tube. The most frequent
site is ampulla. Isthmus is the next common site of implantation of the
ectopic pregnancy after ampulla. The other sites of implantation for the
remaining 5% of the ectopic pregnancy are ovary, peritoneal cavity,
cervix or previous caesarean scar.
Whenever there is a diagnosis of ectopic pregnancy, the possibility
of heterotopic pregnancy should be considered. The incidence of
heterotopic pregnancy is 1 in 30000 pregnancies. However because of the
increased usage of Artificial Reproductive techniques, the incidence has
raised to 1 in 7000 (Mukul LV, Teal SB: 2007)
In tubal pregnancy, due to lack of submucosal layer in the fallopian
tube, the embryo buries through the epithelium. The muscularis is
invaded by the rapidly proliferating trophoblast. In an ectopic pregnancy,
32
Outcomes of tubal pregnancy are:
1. Tubal rupture
2. Tubal abortion
3. Pregnancy failure with resolution.
Tubal rupture: in rupture, the invading products of conception and the
associated haemorrhage causes tears and rents at several sites of the
fallopian tube.
Tubal abortion: with tubal abortion, the products of conception abort out
through the distal end of the tube.
Pregnancy failure with resolution: such pregnancies spontaneously fail
and get absorbed.
Depending on the hemodynamic status, size, beta HCG and other
factors pertaining to ectopic gestation, the management varies.
A ruptured ectopic pregnancy with hemoperitoneum or signs of rupture
would warrant an emergency laparotomy.
Around 40% of women with ectopic pregnancy reveal evidence of
PID. Following an episode of PID, 12.8% of women showed complete or
of salphingitis and 75% following 3 episodes. In women who showed
features suggestive of PID on laparoscopy, there was a seven fold
increase in the incidence of ectopic pregnancies. The incidence of tubal
pregnancies is also more in women who had previous induced abortions
and genital tuberculosis. The incidence of genital tuberculosis is very
high in India.
Ectopic pregnancy accounts for significant maternal morbidity and
mortality, mostly due to haemorrhage. This can be avoided with early
diagnosis and management. The morbidity includes:
1. Infertility
2. Recurrent ectopic pregnancy
3. Pelvic adhesions and chronic pelvic pain
4. Fear of the outcome of future pregnancy and Psychological
morbidity.
With better screening procedures and greater awareness of high
risk cases, the ectopic pregnancy can be considered a lesser life
34
(x) RETAINED PLACENTA:
When placenta is not delivered after 20 minutes of administration
of Brandt- Andrews technique, one should consider the possibility of
manual removal of placenta. A retained succenturiate lobe is considered
when there are torn behind vessels at the edge of the rent in the
membranes.
If there is a history of retained placenta/ hemorrhage during the
previous pregnancy, the current delivery should always be conducted at a
tertiary care centre where facilities for anaesthesia, blood transfusion and
expertise are available.
(xi) AMNIOTIC FLUID EMBOLISM (AFE):
Amniotic fluid embolism is an obstetric emergency in which the
amniotic fluid, fetal hair, cells and other debris enter the maternal
circulation resulting in cardiopulmonary collapse. The reported incidence
varies from 1.9 in 1,00,000 to 6.1 in 1,00,000 (Knight and et al.,
Amniotic fluid embolism incidence, risk factors and outcomes: a review
and recommendations BMC Pregnancy Childbirth 2012). Risk factors for
i.Older maternal age
ii.Induction of labour
AFE was believed to be the commonest cause of obstetric death
during labour or in the first 10 hours after delivery. Fortunately, the
mortality rates decreased from 80-90% in the 1970s to less than 30% in
the more recently reported population studies. There is also a high
incidence of neurological impairment in women who survive AFE
(Tuffnell DJ). The perinatal mortality rate is 9-44%.
Training of labour ward staff to deal with AFE with utmost
urgency is of importance for effective management to reduce mortality
and morbidity. Mock drills and standard protocols are needed to maintain
the level of alertness and skills. A multi-disciplinary team should be
available at the institution.
(xii) PULMONARY EMBOLISM:
It is one of the leading causes of direct maternal mortality in the
Western world. Due to the physiological changes that occur in pregnancy,
women are at higher risk of venous thrombo-embolic disease, as
compared to their non-pregnant counterparts. The diagnosis should be
36
Pulmonary embolism occurs due to the blockage of pulmonary
arteries by a thrombus. About 1 in 10 patients die within first one hour if
treatment is not instituted properly.
PRE-EXISTING DISORDERS, AGGRAVATED DURING PREGNANCY:
ANEMIA:
The Centre of Disease Control And Prevention (CDC)
(1998),defines anemia in iron supplemented pregnant women with a cut
off of the 5th percentile- 11 gm/dl in the first and third trimester and 10.5
gm/dl in the second trimester. Global prevalence of anemia in the world
as estimated by WHO has been 47.4%. India is listed as a country with
high prevalence of anemic women. Anemia is highly prevalent in all age
groups in India.
Iron deficiency starts in childhood, worsens in adolescence and
gets aggravated in pregnancy. Of 1000 Indian women half were anemic
at some point and 40% anemic throughout pregnancy. (Kumar, et. Al,
2013).
Among the causes of anemia in pregnancies, nutritional anemia
due to iron deficiency and acute blood loss were known to be most
preventing and treating anemia during pregnancy. Besides maternal
mortality and morbidity anemia is associated with low birth weight,
IUGR which lead to poor growth trajectory in infancy, childhood and
adolescence and contribute to low adult weight.
In India, 20% of direct or indirect causes of maternal death has
been due to anemia. Other causes of anemia are Megaloblastic Anemia,
Folate Deficiency, Aplastic Anemia and Hemoglobinopathies.
RESPIRATORY DISORDERS:
Acute and chronic pulmonary disorders are frequently encountered
during pregnancy. Chronic asthma or an acute exacerbation is the most
common and affects up to 4% of the women. (Gazmararian JA, et. Al.
2002).
Pregnant women have asthma exacerbation during labour. Up to
20% of women with asthma have been known to have acute exacerbation
intrapartum. Asthma doesn’t affect the obstetric outcome in most cases
when the severity is low or moderate. The risk increases by 2 fold in
pregnant women with severe asthma.(Maternal- fetal medicine units-
38
There is a direct relationship between pregnancy and Forced
Expiratory Volume at One Second (FEV1) with birth weight and an
inverse relationship with rate of gestational hypertension and preterm
delivery.(Schatz M et al 2003).
Pneumonia:
Various causes of pneumonia in pregnancy have been identified,
most common being Community Acquired Pneumonia by streptococcus
pneumonia. (Bogaert, et. Al, 2004).
Another important cause of pneumonia requiring hospitalization in
pregnant women is influenza pneumonia. According to CDC prevention,
2010a, infected pregnant women are more likely to be hospitalised than
normal women, as well as admission to CCU.
PORTAL HYPERTENSION:
Portal Hypertension is when the portal venous pressure exceeds
from its normal pressure of 5-10 mmHg, values may exceed30 mmHg.
Cirrhosis or Extra Hepatic Portal Vein Obstruction leads to portal
venous system hypertension which in turn causes oesophageal varices in
pregnant women. Mortality largely depends upon the presence or absence
EPILEPSY IN PREGNANCY:
Pregnant women have an increased seizure rates with attendant
mortality risks and foetal malformations. Contemporary studies state that
there is increased seizure activity in only 20 to 30% of the women who
are pregnant. (Mawerg, Briggs M et al, 2006) .
Pilo and colleagues (2006) have reported a 1.5 fold increase in the
caesarean delivery, pre eclampsia and postpartum haemorrhage. Children
of epileptic mother have a 10%increased risk of developing seizure
disorder.
The major goal of management of seizure disorder is pregnancy is
seizure prevention. To accomplish this, treatment for nausea and
vomiting is provided, seizure provoking stimuli are avoided and
medication compliance is advised. Routine monitoring of serum drug
levels is not indicated. ( Adab N: 2006).
Women who are on antiepileptic drugs should undergo a targeted
40
CORTICAL VEIN THROMBOSIS:
Strokes, both ischemic and hemorrhagic as well as anatomical
anomalies, such as arterio-venous mal formations, aneurysms are the
abnormalities of Cerebrovascular circulation.
The current endemic of obesity, along with diabetes, hypertension
and heart disease has resulted in increased stroke prevalence (CDC and
prevention, 2012).Pregnancy increases the immediate and lifetime risk of
both hemorrhagic and ischemic stroke. (Jamieson DG, Skliut M: 2010)
Most strokes during pregnancy occur either during labour, delivery
or in the puerperium. In a study conducted of 2850 pregnancy related
strokes, approximately 10% developed stroke ante partum, 40 %
intrapartum and almost 50% postpartum. (James AH et al, 2005).
Lateral and superior sagittal venous sinus thrombosis occurs
usually in the puerperium. It is often associated with pre eclampsia,
sepsis and thrombophilias, with Headache being the most common
presenting symptom.
The prognosis of stroke especially venous thrombosis is better in
pregnant women than in non pregnant women. The mortality rates are
RENAL DYSFUNCTION:
Various changes occur during pregnancy in renal and urinary tract.
Pregnancy induced changes, cause worsening of the disorders of urinary
tract and renal system. Due to increased vesicoureteric reflux, there is an
increased risk of urinary tract infections in pregnancy.
Patients with Chronic Kidney Disease, have an increased risk of
both maternal and perinatal complications. Such complications include-
gestational hypertension, preeclampsia, eclampsia, dysfunctional labour,
caesarean section and maternal mortality. (Nevis IF, et. Al, 2011).
There is an increased pregnancy loss due to spontaneous abortion
and Intra Uterine Death’s. The risk remains high even in women with
unimpaired renal function at conception. Only 65% women had
successful pregnancy outcome with a high incidence of ante
partumanemia, hypertension, preterm labour and foetal growth
restriction. (Pajor A, et. Al, 1991).
Almost 20% of the cases of acute renal failure have been due to
pregnancy related acute renal failure (PR-ARF). These patients have a
42
ACCIDENT/ ASSAULT/ SURGICAL PROBLEMS:
Trauma complicates 6-7% of pregnancies (Connolly A M et. al.).
It is an important cause of non-obstetric death. Major trauma in
pregnancy is due to Road-Traffic accidents, domestic violence and
assault. Foetal mortality varies from 3.4 % to 38 %. Hence, all pregnant
women should be evaluated for maternal and foetal well being regardless
of the severity of maternal injury.
Pregnant women who develop symptoms like, syncope, pain
abdomen, bleeding, blurred vision, convulsion and altered behaviour
should be given due importance and proper maternal and fetal evaluation
must be done.
INFECTIONS:
Pregnancy is associated with suppression of humoral and cell
mediated immunological functions. Maternal and fetal susceptibility to
these infections varies. Viral infections in pregnancy include Rubella,
Cytomegalovirus, HSV, Varicella Zoster, Parvo Virus.
Rubella is the most teratogenic agent known. During first trimester
second trimester and increasing again in the third trimester from 35% to
nearly 100% beyond 36 weeks.
Most cytomegalovirus infection are asymptomatic. More than half
the cases of genital herpes in adolescence and young adults are caused by
HSV1 infections. Most women have an average of 2-4 symptomatic
recurrence in pregnancy.
PROTOZOAL INFECTIONS:
Among the protozoal infections Toxoplasmosis caused by
Toxmoplasma gondii, an intracellular parasite, a zoonotic disease is
common. The risk of infection to the foetus increase during the late
trimester.
HIV:
Pregnancy has minimal effects on CD4 count, HIV RNA levels or
disease progression. Tamilnadu is rated among the states with high
prevalence of HIV (3%) (Progress report 2011: Global HIV/AIDS
response. Epidemic update and health sector progress towards universal
44
AIM OF THE STUDY
The main aim of maternal near miss approach are the reduction of
morbidity and mortality in high risk pregnancies and improve the clinical
practice.
1. To determine the frequency of severe maternal near miss cases.
2. To determine the pattern of MNM occurrence and the causes of
MNM
3. To evaluate health care facility
4. To identify key intervention in the prevention and management of
severe obstetrics complications and child birth.
5. Improvement of the maternal health by identifying the lag in the
MATERIALS AND METHODS
Retrospective and prospective studies were performed.
Data collected about maternal ‘near-miss’ cases admitted in
Government RSRM Lying-in Hospital during the period of January 2016
to June 2017.
Near miss cases were identified and analysed according to the
maternal near miss guidelines published by NRHM, on behalf of The
Ministry of Health and Family Welfare, Government of India, in
December 2014.
Inclusion criteria:
Critically ill pregnant women,
Labouring women,
Postpartum and
Post-abortal women
admitted in Government RSRM Lying in Hospital,
46
Exclusion criteria:
Non pregnant women and women who died due to maternal
morbidities were excluded from this study.
Procedure:
Data was collected from the records of patients admitted to the
Government RSRM lying-in Hospital’s critical care unit, during the
period of January 2016 to June 2017, who satisfied the criteria of
maternal near-miss as per the NRHM guidelines.
Data was compiled to include the parity, date of near miss,
obstetric score, duration of hospital stay, diagnosis, past history,
treatment modalities, neonatal/ maternal outcomes, mode of termination
STATISTICAL ANALYSIS
Statistical analysis was carried out, taking into account the major
causes of maternal morbidity, obstetrics events, outcomes of the neonate
and the mother, interventions needed, and were compared, using
IBM.IPSS statistics software 23.0 Version.
To describe the data, descriptive statistics frequency analysis and
percentage analysis were used for categorical variables and the mean and
SD were used for continuous variables.
Total number of cases during the study period: 182 cases
Frequency of maternal near miss=([ total no. of near miss/total
48
EDUCATION
Frequency Percent
1 4 2.2
2 39 21.4
3 116 63.7
4 23 12.6
Total 182 100.0
1. Illiterate
2. Literate upto 6th standard
3. Literate from 6th standard to 12th standard
4. Beyond 12th Standard
2%
21%
64% 13%
DESCRIPTIVE STATISTICS
N Minimum Maximum Mean Std. Deviation AGE 182 18 37 25.18 4.255
HOSPITAL
STAY
182 5 44 13.07 6.202
ICU STAY 182 1 85 13.16 15.876
BIRTH
WEIGHT
50
DIAGNOSIS
Frequency Percent
ABRUPTIO PLACENTA 22 12.1
ANEMIA 17 9.3
ANEMIA, HELLP 1 .5
AP ECLAMPSIA 23 12.6
ATONIC PPH 10 5.5
GESTATIONAL HYPERTENSION 5 2.7 IMMINENT ECLAMPSIA 2 1.1 INVERSION OF UTERUS 1 .5
OTHERS 25 13.7
PERIPARTUM
CARDIOMYOPATHY
1 .5
PLACENTA PREVIA 3 1.6
PP ECLAMPSIA 10 5.5
RETAINED PLACENTA 5 2.7 RUPTURE UTERUS 3 1.6 RUPTURED ECTOPIC
PREGNANCY
35 19.2
SEVERE PREECLAMPSIA 11 6.0 SEVERE PREECLAMPSIA,
ANEMIA
1 .5
TRAUMATIC PPH 7 3.8
DIAGNOSIS
0 5 10 15 20 25 30 35
52
CONDITOIN ON ADMISSION
Frequency Percent
1 126 69.2
2 29 15.9
3 27 14.8
Total 182 100.0
1. Admitted with severe illnesses
2. Admitted with no disorder and became near miss 3. Admitted with disorder and became near miss
69% 16%
15%
TYPE OF ADMISSION
Frequency Percent
REFERRAL 101 56
SELF 81 44.0
Total 182 100.0
56% 44%
TYPE OF ADMISSION
54
OBSTETRIC SCORE
Frequency Percent
MUTLI GRAVIDA 106 58.2
PRIMI 76 41.8
Total 182 100.0
GESTATIONAL AGE
Frequency Percent
Postpartum 28 15.4 Upto 10 Weeks 42 23.1 11 - 20 Weeks 6 3.3 21 - 25 Weeks 4 2.2 26 - 30 Weeks 16 8.8 31 - 35 Weeks 22 12.1 36 - 40 Weeks 64 35.2 Total 182 100.0
0 10 20 30 40 50 60 70
56
MODE OF DELIVERY
Frequency Percent
NOT TERMINATED/ POSTPARTUM 12 6.6 EMERGENCY HYSERECTOMY 2 1.0 EMERGENCY HYSEROTOMY 7 2.7 EMERGENCY LAPAROTOMY 40 22.0 LABOUR NATURAL WITH EPISIOTOMY 37 20.3
LSCS 76 41.8
SPONTANEOUS EXPULSION 4 2.2 SUCTION EVACUATION 4 2.2 Total 182 100.0
0 10 20 30 40 50 60 70 80
PUERPERIUM
Frequency Percent
NOT DELIVERED 12 6.6 EVENTFUL 47 25.8 UNEVENTFUL 123 67.6 Total 182 100.0
58
BLOOD TRANSFUSION
Frequency Percent
NO 55 30.2
YES 127 69.8
Total 182 100.0
TYPE OF TRANSFUSION
Frequency
NOT TRANSUSED 55
BLOOD 66
BLOOD, FFP 41
BLOOD, FFP, CRYOPRECIPITATE 1 BLOOD, FFP, PLATELETS 10 BLOOD, PACKED CELLS 1
BLOOD, PLATELETS 1
FFP 3
FFP, CRYOPRECIPITATE 1
FFP, PLATELETS 3
Total 182
0 10 20 30 40 50 60 70
60
BABY DETAILS
Frequency Percent
EARLY
WEEKS/NOTDELIVERED/POSTPARTUM
55 30.2
DEAD BORN 22 12.1
LIVE BIRTH 105 57.7
Total 182 100.0
17%
83%
NICU ADMISSION
Frequency Percent
BROUGHT DEAD 1 .5
NICU ADMISSION DISCHARGED 68 37.4
NICU DEATH 8 4.4
1%
88% 11%
62
NO. OF SYSTEMS INVOLVED
Frequency Percent
I 50 27.5
II 115 63.2
III 16 8.8
IV 1 .5
Total 182 100.0
0 20 40 60 80 100 120
ADDITIONAL FACTORS
Frequency
1. DELAY IN REFERRAL 17 2. DELAY IN REFERRAL, LACK OF BLOOD
PRODUCTS AT REFERRAL 2 3. LACK OF AWARENESS 66 4. LACK OF BLOOD PRODUCTS AT
REFERRAL 51
5. REFUSAL OF TREATMENT OR ADMISSION 7
0 10 20 30 40 50 60 70
DELAY IN REFERRAL DELAY IN REFERRAL, LACK OF BLOOD
PRODUCTS AT REF
64
DISCUSSION
On statistical analysis of the data collected from the near miss
cases in our hospital, it has been found that most patients have an
education of 6th standard to 12th standard(63.7%) followed by literate
upto 6th standard (39%). Lack of awareness being a major cause of
maternal mortality at the health care level, education plays an important
role in the prevention of maternal morbidity and mortality.
The mean duration of hospital stay for a patient admitted with
SAMM has been 13 days as an average with a maximum of 44 days
compared to 3 days for a vaginal delivery and 5 days for an LSCS, this
number is significant.
Discussing the diagnosis and hence the causes of the Maternal
Near Miss cases, ruptured ectopic pregnancy as a single entity
contributes significantly to Maternal Near Miss(19.2%).
But when gestational hypertension, AP eclampsia, PP eclampsia,
severe preeclampsia and imminent eclampsia are clubbed together as
hypertensive disorders of pregnancies, 28% of the Maternal Near Miss
pregnancy are the most important cause of maternal morbidity in this
study group.
Others (25 patients, 13.7%) in the study have come out to be the
next major cause; they have no significant numbers when calculated as a
single entity. These include, TB meningitis, Leptospirosis, portal
hypertension, ARDS, septic abortion, bowel injury , seizure disorder etc.
When the condition on admission was studied it has been found
that 69% of patients were admitted with severe illnesses at the time of
admission, 16% of them were admitted with no disorder and 15% were
admitted with disorder at the time of admission, and later became a
‘near-miss’ case.
Most of the Maternal Near Miss cases have come under
referral(54%) which indirectly indicates the lack of resources at the
primary health care level.
Another conclusion from the same statistics can be drawn that at
the primary health care level, the patients seek medical help only when
the illness becomes severe enough and thus are being referred to a tertiary
66
58% of patients classified as ‘Near-miss’ and admitted in ICU were
mutiparas women and 42% being primiparas women.
Although previous studies on near miss cases have shown a
significant relationship between obstetric score of the patient and the
outcome, in this study no such significance has been made out.
An analysis of the frequency of gestational age among these
patients has shown that 35.2% of them were between 36 and 40 weeks of
gestation, 23.1% of them were up to 10 weeks of GA, 15.4% of them
were postpartum women, 12.1% of them were between 31 and 35 weeks
of gestation, 8.8% of the patients were between 26 and 30 weeks of GA,
3.3% of them between gestational age 11 to 20 weeksand2.2% between
21 to 25 weeks of gestation.
In this study, most patients who satisfied the criteria of maternal
‘near-miss’ did not have any significant past history, but a few had
morbidities like gestational hypertension, anemia, hypothyroidism,
seizure disorders.
On analysing the mode of delivery of the MATERNAL NEAR
mode of delivery. LSCS (41%) has been the mode of termination for
these patients.
Except a few patients who have had PP eclampsia, acute kidney
injury, ARDS, all maternal near miss cases have had an uneventful
puerperium.
Taking into account the need for blood transfusion among these
cases, 69.8% of them have needed blood transfusion emphasising the
need for blood transfusion facilities at the referral centres. Non
availability of blood and blood products at the primary level of health
care have contributed significantly to maternal morbidity and mortality.
In cases of obstetric hemorrhage, immediate volume replacement should
be done, which otherwise will result in fatal outcomes to the mother.
Anemia being a major contributor of MATERNAL NEAR MISS, timely
replacement of the lost blood volume in cases of post partum
haemorrhage and APH should be emphasised. In PIH patients who are
presenting with obstetric hemorrhage, the ongoing blood loss is often
seriously underestimated considering the vital signs of the patients. The
blood pressure is almost always normotensive and the pulse rate doesn’t
increase unless there is very significant blood loss. Hence monitoring of
68
hence the proper management of these conditions. Health education at the
referral level about the lethal combination of Post Partum Haemorrhage
And PIH and the importance of timely blood transfusion should be
encouraged. In this group, 30.2% of the patients have needed transfusion
of blood(whole blood and packed cells),
Discussing the fetal outcome of these cases, it has been found that
83% of the births among the cases has been live births, with an average
birth weight of 2 kilograms.
88% of the babies born to these mothers have been admitted to
NICU either for the maternal or the fetal indications. The fetal indications
include fetal distress, perinatal asphyxia, high risk mother, meconium
stained liquor, respiratory distress. The maternal indications include
circumstances in which the mother is sick enough not to feed her baby,
admission of mother in an ICU requiring cardio respiratory support and
inotropic support. NICU death has been recorded among 11% of the
babies and 1% have been brought dead.
115 number of patients (63.2%) have had involvement of more
than one systems in setting of the morbidity. 50 patients (27.5%) have
had single system involvement. This indicates that maternal morbidity is
Discussing the indirect cause of maternal mortality and morbidity
among the near miss cases at the level of community, it can be seen that
lack of awareness among the population contributes primarily to illnesses
in such women. In this study 36.3% of the women had no awareness
regarding pregnancy and pregnancy related conditions. Also lack of
availability of blood and blood products 30% at the primary level
contributes widely to maternal near miss.
As earlier discussed 68% of women admitted as near miss have
needed blood or blood product transfusion emphasising the need for
70
SUMMARY
The frequency of near miss in this study is 12/1000 live births
which is less when compared to other study group in the mentioned
literature. The frequency has been 16.8%/1000 live births in a study
conducted at Kasturba hospital, Manipal. The frequency of near miss
cases depends on the level of health care at each level of the society, the
health seeking behaviour of the population, quality of resources at the
referral level and available manpower.
Although 63.7% of the patients who come under near miss are
literate upto 12th standard, health awareness has been low and hence
have caused such morbidities. Providing health education at the primary
and middle school level should be considered . 28% of the patients in the
study group have hypertensive disorders of pregnancy, which is the most
common cause of morbidity in this study group.
69% of the patients were admitted with severe illnesses at the time
of admission itself and 54% have been referred from other centres,
which indicates lack of health care and resources at the primary level.
Almost one third (35%) of these patients had a gestational age of
blood transfusion during any period, antenatal or postnatal which
indicates the need for making blood transfusion facilities more accessible
to the primary health care level. Almost 30% of the near miss cases have
been referred to higher centre due to lack of blood transfusion facilities
at the referral level. 36% of these patients have had no awareness of the
complications of the disorders that come along with pregnancy
emphasising the need for education about pregnancy related problems
during antenatal period.
Although haemorrhage has been the most common cause of
morbidity in the previous studies mentioned, in this study group,
hypertensive disorders of pregnancy followed by ruptured ectopic
pregnancy.
This is primarily due to timely identification and prompt
replacement of blood and blood products in the hospital of this group.
Since most of the cases have been referred from this indirectly indicates
that facilities for storage and transfusion of blood should be made
72
Hence, it can be concluded that the occurrence of near-miss cases
is primarily due to:
1. Lack of Material
2. Lack of Manpower
3. Lack of Infrastructures.
Facilities for blood transfusion, blood storage, quick referral should
be made available at the primary level. Prompt replacement of the lost
blood volume is of vital importance in cases like post- partum and
ante-partum haemorrhage.
Lack of manpower can be alleviated by appointing skilled health
care providers at least at the district level and community level.
Educating staffs about the emergencies in obstetrics, conducting mock
drills to handle emergency situations, conducting training programmes
for improving obstetric skills can help.
Lack of infrastructure can be solved by the joint effort of the health
providers at the Primary health care level and the government by
providing adequate funds and facilities. The government and the health
care providers must also ensure that these facilities and funds are utilised
The success of reducing the incidence of near miss cases also
depends upon the proper patient education and raising the awareness
74
CONCLUSION
It can be concluded from this study that hypertensive disorders of
pregnancy are the most common cause maternal morbidity in the study
group, followed by ruptured ectopic pregnancy. Hence, facilities at the
community level that aid in early identification, treatment and proper
referral of pregnancy induced hypertension should be made available.
Education of the primary health care staff about the normal blood
pressure among antenatal mothers, causes of hypertension, diagnosis,
quantification of proteinuria and further evaluation of the disorder and
timely referral should be given.
The next major cause of maternal near miss is ruptured ectopic
pregnancy. Creating awareness among the general population about
ectopic pregnancy and its complications, motivating them to do ultra
sonogram of abdomen and pelvis at the early weeks of pregnancy would
alleviate the morbidities due to ruptured ectopic pregnancy.
Further in this study, it can be concluded that apart from health
education, making facilities for blood transfusion at the primary health
care level or setting a tertiary health care centre in every district can
undoubtedly prevent morbidity. Establishment of tertiary care centre in
inadequate utilisation of resources are the other major causes of
morbidity.
Along with health education, proper utilisation of resources at
primary level of care and awareness on ones’ own health, quality of
BIBLIOGRAPHY
1. Adab N:Therapeutic monitoring of anti epileptic drugs during
pregnancy and in the postpartum period. Is it useful? CNS drugs
20:791, 2006.
2. Bansal M et. al, Int J Reprod Contracept Obstet Gynecol, 2016-
March 5(3):620-623.
3. Bendetto C, et. Al, biochemistry of HELLP syndrome,
AdvClinKhem, 2011.
4. Bogaert, et. Al, Streptococcal pneumonia colonisation: the key to
pneumococcal disease, Lancet Infect Dis, 4:144, 2004.
5. Campbell OM, Graham WJ, Lancet Maternal Survival Series
Steering Group. Strategies for reducing maternal mortality: getting
on with what works. The Lancet, 2006,368:1284–1299.
6. Capriola M, Peripartum cardiomyopathy a review, int j womens
health 2013.
7. Chames MC et al, Late postpartum eclampsia a preventable
severe maternal morbidity in a tertiary hospital of Delhi, India:
A pilot study. Trop Doct. 2008;38:201–4.
9. Connolly A M et. al, trauma and pregnancy, Am J Perinatol 1997.
10. Duckitt K, et. Al., risk factors for preeclampsia at antenatal
booking : systematic review of control studies, BMJ 2005.
11. Freedman LP et al. Practical lessons from global safe motherhood
initiatives: time for a new focus on implementation. The Lancet,
2007, 370:1383– 1391.
12. Gazmararian JA, et. Al. Hospitalizations during pregnancy among
managed care enrollees, Obstetgynecol, 100:94, 2002.
13. Graham WJ. Criterion-based clinical audit in obstetrics: bridging
the quality gap? Best Practice & Research Clinical Obstetrics &
Gynaecology, 2009, 23(3):375–388. 10. Introducing WHO’s
sexual and reproductive health guidelines and tools into national
programmes: principles and process of adaptation and
14. H. S. Nielsen and T. M eggebo, “Millenium developmental goal
5- An obstetrics challenge”, acta obstetrics et gynaecologist
scandanavia, vol 91, no. 9., pg: 1007-1008, 2012
15. International statistical qualification of diseases and related health
problems. Tenth revision, who 1993.
16. Jaiyeoba O: Post operative infections in Obstetrics and
gynaecology. ClinObstetGynaecol 55(4):904,2012.
17. James AH et al: Incidence and risk factors for stroke in pregnancy
and in the puerperium. Obstetric and Gynecol, 2005.
18. Jamieson DG, Skliut M: Stroke in women: what is different?
CurrAtheroscler Rep 12:236, 2010; Jung SY, Bae HJ, Park BJ et
al: parity and risk of hemorrhagic strokes. Neurology 2010.
19. Kumar, et. Al, maternal anemia on various trimesters and effect in
newborn weight and maturity, intj PREVMED, 2013.
20. Lojo, mission JF et. Al., hypertensive disease of maternal
mortality, CURR opinobstetgyneco, 2013.
21. Magee LA, Heleva M et al. Hypertension guideline committee;
management of the hypertensive disorders of pregnancy. J
ObstetGynaecol Can 2008 Mar.
22. Mawer g, Briggs M et al, Pregnancy with epilepsy: obstetric and
neonatal outcome of a controlled study, 2010; Vajda FJ et al:
seizure control in anti epileptic drug treated pregnancy, 2008;
Viinikainen et al: Community based, prospective, controlled study
of obstetric and neonatal outcome of 179 pregnancies in women
with epilepsy, 2006 .
23. mccaulley et al: Postpartum cerebral venous thrombosis.
Obstetgynecol, 2011.
24. Ministry Of Health And Family Welfare, Govt. Of India; District
Household And Health Survey (DLHS)- 3 Maharashtra,
2007-2008.
25. Mukul LV, Teal SB: current management of ectopic pregnancy.
ObstetGynecolClin North Am , 2007.
26. Nevis IF, et. Al, pregnancy outcome in women with chronic kidney
27. Pajor A, et. Al, pregnancy in women with chronic renal disease, a
14 year study, Actachir hung, 1991.
28. Pattinson R et al. WHO maternal death and nearmiss
classifications. Bulletin of the World Health Organization, 2009,
87:734–734A.
29. Pattinson RC, Hall M. Near misses: a useful adjunct to maternal
death enquiries. British Medical Bulletin, 2003, 67:231–243.
30. Phua J, Badia JR et al: Has mortality from Acute respiratory Stress
Syndrome decreased over time? A Systematic Review. Am J
Respir Crit Care Med 2009.
31. Prakash Prabakar Rao Doke- Maternal Morbidity And Community
Studies In India: 10.5005/ JP journals – 10036-1011.
32. Report on the World Health Organization Working Group on the
Classification of Maternal Deaths and Severe Maternal
Morbidities. Geneva, World Health Organization, 2009.
33. Ronsmans C, Fillipi V. Beyond the Numbers: Reviewing Maternal
Deaths and Complications to Make Pregnancy Safer. Geneva,
complications; pp. 103–24.
34. Roopa PS Et. Al, Journal Of Pregnancy , Vol. 2013; “Near-Miss
Obstetric Events And Deaths In A Teritiary Care Hospital And
Audit”.
35. Say L et al. WHO systematic review of maternal morbidity and
mortality: the prevalence of severe acute maternal morbidity (near
miss). Reproductive Health, 2004, 1(1):3 (DOI:10.1186/1742–
4755–1-3).
36. Say L et al., WHO working group on Maternal Mortality and
Morbidity Classifications. Maternal near miss–towards a standard
tool for monitoring quality of maternal health care. Best Practice &
Research Clinical Obstetrics & Gynaecology, 2009,23:287–296.
37. Say L, Souza JP, Pattinson RC, Maternal near miss towards a
standard tool for monitoring quality of maternal health care. Best
practice and research. 2009;23(3): 287-304
38. Schatz M et al Asthma morbidity during pregnancy can be
39. Stones W, limw, Al Azzawi F, Kelly M. An investigation of
maternal morbidity with identification of near miss episodes.
40. Tuffnell DJ. Amniotic fluid embolism. Curr Opin Obstet Gynecol
2003.
41. Ujah IA, et, al,. Factors contributing to north central Nigeria, a 17
year review, Afr J reprod health, 2005.
42. WHO systematic review of maternal morbidity and mortality; the
prevalence of sever acute maternal morbidity (near miss)
reproduction health 2004
43. Williams obstetrics 24th edition
44. World Health Organization, UNICEF, UNFPA and The World
Bank. Trends in maternal mortality: 1990 to 2008. Geneva: World
Health Organization, 2010 2.
45. World Health Organization. Maternal Mortality in 2005: estimates
Developed by WHO, UNICEF, UNFPA, and the World
Bank. Geneva, Switzerland: World Health Organization; 2010.
NAME : AGE :
EDUCATION: IP NO : D.O.A :
D.O.DELIVERY : D.O. NEAR MISS: D.O.DISCHARGE : TYPE OF ADMISSION: LMP :
EDD :
DURATION OF HOSPITAL STAY DURATION OF ICU STAY: OBSTETRIC CODE : GESTATIONAL AGE :
ADDRESS AND CONTACT NO :
PRESENTING COMPLAINTS : MENSTRUAL HISTORY :
MARITAL HISTORY :
OBSTETRIC HISTORY :
PAST HISTORY :
GENERAL EXAMINATION : HEIGHT :
WEIGHT : ANAEMIA : EDEMA : PULSE RATE : BP :
CVS : RS:
OBSTETRIC EXAMINATION: P/A EXAMINATION:
DIAGNOSIS:
DATE AND TIME OF INDUCTION: INDICATION FOR INDUCTION: MODE OF DELIVERY:
BABY WEIGHT: BABY SEX: APGAR: PUERPERIUM: INTERVENTION:
S. N O N A M E A G E E D U CA T D O N M H O SP IT A L IC U ST A D IA G N O CO N D IT IO A D M IS SI T Y P E O F A D M R E FE R R E D O B S SC O P E R IO D G E ST A T D IS O R D E R A D M IS SI A N V IS IT R E FE R R A L N O A N CA P A ST H IS T
1 PRIYA 20 4 02/10/16 10 D H AP ECLAMPSIA 1 REF PVT P 30 W AP ECLAMPSIA R Y
2 POONGODI 23 3 27/8/2016 10 D 2 18 H ABRUPTIO PLACENTA 1 S M 28 W ABRUPTIO PLACENTA R GESTATIONAL HYPERTENSION 3 THAJUN NISHA 24 4 26/5/2016 10 D H AP ECLAMPSIA 1 S P 28 W AP ECLAMPSIA R GESTATIONAL HYPERTENSION 4 CHITHRA 26 3 19/8/2016 10 D 2 12 H ABRUPTIO PLACENTA 1 REF PVT M 36 W ABRUPTIO PLACENTA/SEVERE PREECLAMPSIA IR Y SEVERE PREECLAMPSIA 5 VARALAKSHMI 26 3 09/01/16 10 D H INVERSION OF UTERUS 1 REF EOC M PP INVERSION R Y
6 SATHYA 26 3 28/8/2016 10 D 1 15 H RUPTURED ECTOPIC PREGNANCY 1 S P W RUPTURED ECTOPIC PREGNANCY R PCOS/IUI DONE 7 MEERA BANU 25 3 09/02/16 10 D 2 14 H RUPTURED ECTOPIC PREGNANCY 1 REF PVT P W RUPTURED ECTOPIC PREGNANCY IR Y Y
8 KALAIARASI 26 4 09/03/16 10 D H PPH 1 REF PHC P PP TRAUMATIC PPH R Y
9 SOUNDARYA 18 3 27/07/16 10 D D PP ECLAMPSIA 1 REF PHC P PP PP ECLAMPSIA R Y
10 HEMAVATHY 23 4 04/03/16 10 D H PP ECLAMPSIA 2 REF EOC P 40 W R Y BRONCHIAL ASTHMA
11 SHANAVAS 18 3 29/3/2016 10 D 2 18 H PP ECLAMPSIA 1 REF PHC P PP PP ECLAMPSIA R Y
12 PAULIN VASANTHA 26 3 19/9/2016 10 D D ANEMIA 1 S M 39 W ANAEMIA IR ANAEMIA
13 RESHMA 27 2 23/8/2016 10 D D AP ECLAMPSIA 1 S M 34 W AP ECLAMPSIA R PREECLAMPSIA
14 SUDHA 27 3 03/11/16 11 D H ABRUPTIO PLACENTA 1 S P 37 W ABRUPTIO PLACENTA/SEVERE PREECLAMPSIA R
15 SOUNDARYA 21 3 28/6/2016 11 D 1 17 H PP ECLAMPSIA 2 REF GH P 37 W R Y
16 HARITHA 19 3 29/7/2016 11 D AP ECLAMPSIA 1 REF PVT P 36 W AP ECLAMPSIA R Y
17 HASEENA 20 3 01/10/16 11 D H AP ECLAMPSIA 1 REF PVT M 32 W AP ECLAMPSIA R Y GESTATIONAL HYPERTENSION 18 NASRATH BANU 24 4 25/9/2016 11 D AP ECLAMPSIA 1 S P 31 W AP ECLAMPSIA R GESTATIONAL HYPERTENSION
19 LAKSHMI 27 3 10/07/16 11 D D PP ECLAMPSIA 1 REF PVT M PP PP ECLAMPSIA R Y
20 LALITHA 28 3 22/9/2016 11 D 14 H RUPTURED ECTOPIC PREGNANCY 1 REF PVT M W RUPTURED ECTOPIC PREGNANCY IR Y Y ECTOPIC PREGNANCY 21 AFIFA 28 3 23/9/2016 11 D 2 18 H ABRUPTIO PLACENTA 1 S M 37 W ABRUPTIO PLACENTA R ANAEMIA 22 AARTHI 20 4 25/9/2016 11 D 1 22 H AP ECLAMPSIA 1 REF PHC P 36 W AP ECLAMPSIA R Y
23 BALAABIRAMI 22 3 06/07/16 11 D H AP ECLAMPSIA 1 S M 32 W AP ECLAMPSIA R
