The Clinical Study Of Factors Relating To The Outcome Of Maternal Near Miss

BackgroundMaternal mortality rate (MMR) is an important indicator to measure a country orregion’s socioeconomic development and health care development. Maternal nearmiss (MNM) is referred to a woman who nearly died but survived a complication thatoccurred during pregnancy, childbirth or within42days of termination of pregnancy.In the recent years, people recognized that the maternal death is the extreme outcomeof severe maternal morbidity, just revealing the tip of iceberg. However, plenty ofinformation relating to improve the obstetrical care could be got if focus on analysisof maternal near miss cases because of its high incidence. At the end of2009, WHOproposed maternal near miss criteria which combined with clinical signs, laboratorytests and managements. So far material on obstetric critical care according to theWHO criteria was rare.The existing literature about Chinese critical obstetric care mainly concentratedon the specific disease and maternal death, and the surveillance network of maternalnear miss just launched in some provinces and cities the latest year. So far a blueprintfor critical obstetric patient requiring ICU admission has not been developed.Based on these considerations, the study analyzed the data of obstetric patientsadmitted to the ICU of the Obstetric Critical Care Center of Guangzhou, aiming toexploring the clinical characteristic of Chinese maternal near miss and also factorsthat influenced maternal outcome, and to propose a blueprint for obstetric critical care.Maternal cardiac arrest, directly cause of maternal death, and severe sepsis, the majorkiller of patients in ICU, also been deeply analyzed. Chapter I Clinical characteristics and prognostic factors of maternal near missrequiring ICU admission: a5-years reviewObjectiveThe purpose of this study was to describe clinical characteristics of maternal nearmiss in relating to the disease distribution, managements and prognostic factors ofmaternal outcome. Summarizing the experiences and lessons and then giving someadvice to improve the obstetric critical care.Materials and MethodsThis was a retrospective study. Totally, data of414cases of maternal near missaccording to the WHO criteria admitted to the ICU of the Critical Care Center ofGuangzhou during a5-years study period (2007～2011) were collected. The medicalrecords including age, obstetric history, parity gestational weeks, coexisting medicaldisorders, critical symptoms, managements in ICU, length of hospital stay, ICU lengthof stay, maternal and perinatal outcomes and others were collected. The APACHEⅡscore was also calculated within the first day admitted to the ICU.Statistical analysis: SPSS (v.13.0) software was used for statistical analysis.Student’s test, Mann-Whitney U test and Pearson’s Chi-square test were used tocompare the women’s characteristics between groups. Binary logistic regressionanalysis was used to explore the prognostic factors of the maternal death. A P value<0.05was considered to be statistically significant.Results1. During the5-yr study period,414women admitted to the general ICU were eligiblefor the study according to WHO criteria, among which331cases (80.0%) ofmaternal near miss (MNM) and83(20.0%) maternal death (MD) were identified.There was a total18,171live birth (LB) in the hospital, giving an MNM incidenceratio18.2/1000LB, and Severe maternal outcome ratio (SMOR)22.8/1000LB, andMMR456.8/100,000. MNM:1MD was4.0:1, and Mortality Index0.2.2. The cause of admission to ICU was due to obstetric disorders in246patients(59.4%) and medical disorders in168patients (40.6%). MMR was higher inwomen admitted with medical disorders comparing with obstetric disorders (30.4% vs13.0%, P＜0.001). The proportion of medical disorders slightly declined from38.5%in2007to31.8%in2009, then continuously increased to49.1%in2011.3. In a descending order, hypertensive disease of pregnancy (134,32.4%), majorobstetric hemorrhage (85,20.5%), sepsis (49,11.8%), hepatic diseases (42,10.1%)and cardiac disease (24,5.8%) were the primary diagnoses when women admittedto ICU, and accounted for80.7%(334/414) totally.4. In a descending order, the main causes of maternal death were sepsis (21,25.3%),hepatic diseases (12,14.5%), hypertensive disease of pregnancy (11,13.3%), majorobstetric hemorrhage (10,12.0%), and cardiac diseases (7,8.4%).5. Among263women admitted antepartum, only13(4.9%) survived and continuedtheir pregnancies. One hundred and sixty-two women with190fetuses (gestationalage≥28weeks) gave birth in our hospital. Fetal mortality rate was13.7%(26/190)and Caesarean section rate was90.0%(171/190).6. Analysis of organ dysfunction revealed that cardiovascular (119,28.7%), centralnervous (92,22.2%), and respiratory system(89,21.5%) were the first threesystems involved, and153cases of multiple organ dysfunction syndromes (MODS)developed, resulting in72maternal death (72/153,47.1%). Maternal mortality rateincreased with the numbers of dysfunctional organ.7. Comparing to MNM, the incidence of shock, cardiac arrest, DIC, creatinine≥300umol/L, and acute thrombocytopenia (<50000platelets) in maternal deathwere higher (all P<0.05). The utilization rate of vasoactive drug, ventilation for≥60minutes unrelated to anaesthesia, and dialysis for acute renal failure in maternaldeath were higher than that in maternal near miss (all P<0.05).8. APACH II scores (first day admission to ICU) were higher in non-survivors than insurvivors (median14vs21, P<0.001). Area under curve (AUC) for APACH IIscores as predictor of maternal death was0.834. APACH II score according to themaximum Yoden index was18.5.9. On binary logistic regression analysis, APACH II scores>18.5(P<0.001), cardiacarrest (P=0.022), MODS (P<0.001), use of continuous vasoactive drug (P<0.001),and ventilation for≥60minutes unrelated to anaesthesia (P<0.001) were risk factors independently correlating with maternal death, instead of obstetric disorderas protective factor (P=0.004).Conclusion1. This is the first report on the obstetric critical illness of Chinese populationfulfilled the criteria for maternal near miss according to the WHO proposal.Hypertensive disease of pregnancy, major obstetric hemorrhage, sepsis, hepaticdiseases and cardiac disease were first five diseases responsible for maternal nearmiss and ICU admission in Guangzhou.2. Medical diseases, the proportion of which increasing year by year, resulted inmore maternal near miss and ICU admissions than obstetrical disorders.3. Maternal mortality rate due to infection was the highest in ICU admission. Greaterseverity of illness, cardiac arrest and MODS adversely affect maternal outcome.Particular attention should be paid to protect the function of respiratory andcardiovascular system when treating maternal near miss.4. It is recommended that women identified as maternal near miss according toWHO criteria should be transfer to ICU as early as possible, and those notmeeting the criteria but presenting potential life threatening conditions should betransfer to high dependency unit.Chapter II Analysis of the cause and clinical characteristics of maternal cardiacarrest: a report of51casesObjectiveCardiac arrest is catastrophic event for obstetric patients. Study revealed cardiacarrest was risk factors independently correlating with maternal death. This study aimsto analyze the cause of maternal cardiac arrest and the factors associated the quality ofcardiopulmonary resuscitation.Material and MethodsThe data of all cases of maternal cardiac arrest from October2006to September2011in the Critical Care Center of Guangzhou was retrospectively studied.Results 1. A total of51maternal cardiac arrests were collected and there were18,171deliveries during the study period giving the incidence of rate as1:757.2. Among47(92.2%) cases of intrauterine pregnancies,7cases of cardiac arrestoccurred in prenatal period,3in the process of vaginal delivery,7in the process ofcesarean section, and30in postpartum period.3. Except for5cases of rescue failure, the rest of46patients returned spontaneouscirculation after basic life support, and18mothers (35.3%) survived finally. Thematernal mortality rate due to cardiac arrest was64.7%(33/51).4. Chronic medical disorders existed in16patients (31.4%). The causes of cardiacarrest due to obstetric disorders were found in26women, and due to non-obstetricdisorder in25women. Maternal mortality rate between the two groups showed nostatistical significance (61.5%vs68%, P=0.629).5. The causes of arrest in descending order were hemorrhagic shock (12,23.5%),septic shock (10,19.6%), cardiac disease (7,13.7%), amniotic fluid embolism (6,11.8%), hypertensive disease of pregnancy (3,5.9%), spontaneous intracerebralhemorrhage (3,5.9%), anaesthetic complications (3,5.9%) and other occasionalcauses.6. No mother survived in cardiac arrest due to cardiac disease (7/7) and spontaneousintracerebral hemorrhage (3/3).7. The mother survived rate was highest as68.8%(11/16) when arrest occurred inoperation room.8. Cardiopulmonary resuscitation resulted in each1case of traumatic fracture andpneumothorax. Six of the18survival women showed ischemic encephalopathy aftercardiac arrest.9. In6of the14cases of cardiac arrest occurred before fetus delivered, perimortemcaesarean section (PMCS) was performed. In the6PMCSs,4mothers and4childrensurvived. In the other8cases without PMCS, no prenatal survived.Conclusion1. Hemorrhagic shock, amniotic fluid embolism and severe preeclampsia/eclampsiawere major obstetric causes of maternal cardiac arrest. Septic shock and cardiacdiseases were major non-obstetric causes. Prevention and cure these diseases atearly stage may reduce the possibility of maternal cardiac arrest.2. Cardiac arrest occurred in operation room where maternal survival rate was higherthan that in the other places. 3. Effective cardiopulmonary resuscitation should be started as soon as possiblewhen cardiac arrest occurred, with consideration for maternal physiologicalparticularity.4. Timely PMCS may ensure the optimal outcomes both for mother and fetus.Chapter III Analysis of maternal severe sepsis and septic shock:a report of87casesObjectiveSevere sepsis and septic shock is the most common death in intensive care unitworldwide. Study revealed the maternal mortality due to sepsis was the highest thanother diseases. This study aimed to describe the cause and clinical characteristic ofmaternal severe sepsis and septic shock in intensive care unit.MethodsThe data of all maternal severe sepsis and septic shock from October2006toSeptember2011in the general ICU of the Critical Care Center of Guangzhou wasretrospectively studied.Result1. A total of87cases of maternal severe sepsis were collected and38cases (43.7%)of septic shock developed. Severe sepsis was the primary diagnosis due to ICUadmission in65(74.7%) women and22(25.3%) women admitted to ICU forother causes.2. Fifty-four (62.1%) mothers survived and33(37.9%) mothers died.3. The primary sepsis located in lung (46,52.9%), liver (16,18.4%), genital tract (7,8.0%), urinary tract (5,5.7%), intra-abdominal (5,5.7%), pancreas (4,4.6%) andothers (4,4.6%).4. Maternal mortality rate was53.3%in women suffered lung infection,42.9%ingenital tract infection,25.0%in pancreatitis,20.0%in peritonitis and6.3%invirus hepatitis. No maternal death resulted from urinary tract infection.5. Maternal mortality due to lung infection was70.0%(14/20) in women withchronic underlying diseases, and47.4%(9/19) in women without coexistingdisorders, and16.7%(1/6) in women with tuberculosis.6. Seven women suffered severe genital tract infection, and3of the5patients whogiving birth at home died in postpartum period.7. Only34cases (34/87,39.1%) of blood sample were taken for bacterial culture.Positive blood culture rate was41.2%(14/34). 8. On binary logistic regression analysis, APACH II scores (first day admitting toICU), shock, and MODS were risk factors independently correlating withmaternal death (all P<0.001), instead of surgical infection as protective factor(P<0.001).9. Among62cases of severe sepsis in pregnancy,48cases (77.4%) terminatedpregnancies for severe sepsis or septic shock. Premature delivery rate was77.1%(37/48) and Caesarean section rate was64.6%(31/48). Fetus loss rate was58.8%(37/63), and5cases of severe sepsis recovered and pregnancies continued.Conclusion1. The single most common source was lung responsible for maternal severe sepsisrequiring ICU admission. Maternal severe pulmonary infection in women withchronic underlying diseases had poor outcome.2. Surgical severe sepsis in pregnancy had better outcome.3. Greater severity of illness at the time of ICU admission, shock and MODSassociated with an increased risk of maternal death in patients suffering severesepsis or septic shock.4. It is recommended that cardiovascular function of obstetric patients with severesepsis or septic shock should be evaluated routinely.5. Severe sepsis or septic shock is not always the indication for delivery. Fetalsurvivals rely on improved maternal condition.