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Near miss

1. Maternal Near Miss and Death Among Women with Eclampsia Using WHO Near Miss Criteria Debnath Ghosh 1,2·Snehamay  Chaudhuri 1· Bheshna  Sahu 1·Anwesha   Chakraborty 1

2. ABSTRACT OBJECTIVE : The aim of the study was to estimate the prevalence of maternal near miss (MNM) and maternal death and to identify the factors associated with severe maternal outcome in women with eclampsia according to the World Health Organization (WHO) maternal near-miss criteria. METHOD : A cross-sectional study was carried out over a period of 12 months incorporating pregnant women diagnosed as eclampsia during antepartum and postpartum period. The defi nition of maternal near miss was applied according to the WHO near-miss criteria. Data were collected in a case record form specially designed for the study and analyzed using statistical software.

3. RESULT : A total of 229 women with eclampsia included in the study over a period of 1 year. Among 229 women with eclamp sia , 75 (32.75%) women diagnosed as maternal near miss (MNM), and 6 (2.62%) women had maternal death. Causes of near miss were neurological dysfunction (30.66%), respiratory dysfunction (24%), hematological dysfunction (18.67%), cardiological dysfunction (16%), hepatic dysfunction (10.67%) and uterine dysfunction (5.33%). Maternal near-miss ratio is 4.91 per 1000 live births, and severe maternal outcome ratio is 5.30 per 1000 live birth. Maternal near-miss mortality ratio (MNM:1MD) is 12.5:1, and mortality index is 7.40.

4. Conclusion: The study shows that there is scope to improve antenatal care and utilization of health facilities. Early diagnosis, good perinatal supervision and appropriate treatment can ameliorate many cases.

5. Introduction : At the country level, Nigeria and India are estimated to account for over one-third of all maternal deaths world wide in 2015, with an approximate 58,000 maternal deaths (19%) and 45,000 maternal deaths (15%), respectively [ 1 ]. Eclampsia is responsible for 2.2–9% of maternal death and about 24.5–48% of perinatal death in India [ 2 ]. However, maternal mortality (MM) is considered as “Just tip of the iceberg,” as a vast base to iceberg in the form of severe maternal morbidity (maternal near miss (MNM)) is largely undescribed. It has been estimated that maternal near-miss cases are 60 times more frequent if eclampsia occurs, when compared with women without this condition [ 3 ].

6. The life-threatening complications that are often associated with eclampsia include placental abruption, HELLP syndrome, thrombocytopenia, disseminated intravascular coagulation, acute pulmonary edema, cerebrovascular accidents and acute renal failure. In the past two decades, there has been increasing inter est in the study of severe maternal morbidity (SMM) cases, including its more severe component—the maternal near miss (NM). In 2009, the World Health Organization (WHO) defined concepts and standardized criteria to identify NM cases, after the identification of organ dysfunction and/ or failure as the main determinants of severity. The WHO defined maternal near miss as—“A women who nearly died but survived a complication that occurred during, pregnancy, child birth, or within 42 days of termination of pregnancy” [ 4 ]. In other words, according to the criteria proposed by the WHO to identify maternal near-miss cases, the identification of organ dysfunction and/or failure is considered as main determinant of severity.

7. According to the WHO concept of maternal near miss, eclampsia is considered as “potentially life-threatening condition” which may progress to “life threatening condition (organ dysfunction)” and eventually death (maternal near miss and maternal death) [ 4 ]. Clinical studies have shown that a large proportion of women suffering from eclampsia progress to develop organ dysfunction and eventually die. The burden of each segment of the continuum and identifying the factors affecting the progression is essential for designing interventions.

8. The objectives of the study are to estimate the prevalence of maternal near miss (MNM) and maternal death (MD) in women with eclampsia according to the World Health Organization (WHO) mater nal near-miss criteria and to identify the factors associated with severe maternal outcome in women with eclampsia.

9. Methodology: This prospective cross-sectional study was conducted in the Department of Obstetrics and Gynecology, Midnapore Med ical College and Hospital, West Bengal, India, from April 2021 to March 2022. This is a tertiary care hospital located in a town of district headquarters. The hospital provides free reproductive and child health services and comprehensive emergency obstetric care and equipped round the clock ultra sonography and laboratory facilities for blood parameters examination, nephrology department with hemodialysis facilities, ICU and blood bank with round the clock avail ability of blood and blood products.

10. The study was approved by the Institutional Ethics Committee (Ethical Committee approval no—MMC/IEC-2021/435/(12) dated 18/02/2021), and informed consent was obtained from the legal guardian of all the women with altered sensorium or from the woman herself if she was fully conscious. Sample size was calculated to be 228 using prevalence of severe maternal outcome with eclampsia from the previous study as 18.06% [ 3 ] considering 5% absolute precision and 95% confi dence interval. Women diagnosed as eclampsia were included in the study, and women having eclampsia with pre-existing organ dys function before onset of eclampsia were excluded from the study.

11. The cases were classified according to the WHO criteria into potentially life-threatening condition (PLTC/non severe maternal outcome) and severe maternal outcome. The variables studied were: sociodemographic characteristics, obstetric history, history of previous disease, patient access to obstetric care, mode of delivery, perinatal results, clinical complications and advanced life support interventions (excluding all those already defined as near-miss criteria). During the data collection period, daily visits were made to the wards of the hospital where women with eclampsia, whether antepartum, intrapartum or post-partum were admitted and treated.

12. During the daily visit, the attending nursing staff and doctors were contacted, and the medical charts of hospitalized women screened for the study inclusion criteria. The data were collected on a case record form specially developed for this purpose. After resolution of each case, the consistency and availability of the information on the form reviewed by the senior obstetrician, and the data were inserted into a database using Microsoft Excel software. The study was conducted while maintaining all confidentiality. The main outcome measures were prevalence of maternal near miss, maternal death case fatality rates, maternal near miss indices and factors effecting severe maternal outcome

13. Results: During the study period, total number of women admitted for delivery 18672, out of which 229 (1.22%) were eclampsia patients. Women with severe maternal outcome are 81 (35.37%), women with maternal near miss are 75 (32.75%) and there were 6 (2.62%) maternal deaths (Fig.  1 ). Table 1 shows baseline demographic data of study populations, mean age was 20.27 ± 4.03 years, 82% were primigravida, 45% had primary level of education, 57% belong to lower class of socioeconomic status and mean period of gestation was 36.44 ± 1.71 weeks.

14. NUMBER OF WOMEN ADMITTED FOR DELIVERY (N-=18672) WOMEN WITH ECLAMPSIA(N=229) (1.22%) WOMEN WITH SEVERE MATERNAL OUTCOME (N =81) (35.37%) WOMEN WITH MATERNAL NEAR MISS (MNM) (N =75) (32.75%) WOMEN WITH MATERNAL DEATH (N =6) (2.62%) Fig. 1 Flowchart showing events in the reproductive process

15. Table 1 Baseline demographic data of study populations

16. Table  2 shows that mean age of the study populations having severe maternal outcome was 20.23 ± 4.04 years, 83% of study populations having severe maternal outcome did not have proper antenatal visit, 60.49% of study popula tions had ≥ 3 episodes of convulsion, 70% of severe maternal outcome group were referred from other referral centers, 71% of the same group had proteinuria ≥ 2 + on urinary dip stick examination and 39% of the severe maternal outcome group had convulsion to MgSO4 start interval > 6–12 h.

17. On univariate analysis, unbooked and irregular antenatal visit ( p = 0.000419), patients having ≥ 3 convulsions ( p = 0.03), patients referred from other health centers ( p value = 0.00001), patients having altered sensorium (unconscious + irritable) ( p = 0.00002), patients having proteinuria of urine dipstick ≥ 2 + ( p = 0.03), convulsion to MgSo4 start interval > 6–12 h ( p = 0.006), increased systolic BP ( p value = 0.02), increased diastolic BP ( p = 0.01), patients with decreased hemoglobin value ( p = 0.03), decreased platelet count ( p value = 0.019), increased creatinine level ( p = 0.01) and increased serum bilirubin level ( p = 0.004) are significantly associated with severe maternal outcome.

18. Table  3 shows that, in our study population, 24 (10.49%) were still birth, and among severe maternal outcome group, 17% were still birth. Among study population, 43.66% were low birth weight babies, and 54.32% of severe maternal outcome group had low birth weight babies. About 59% of babies of severe maternal outcome group admitted to NICU. In our study, a total number of patients with perinatal mortality were 61 (26.63%). On univariate analysis of different perinatal outcomes with severe maternal outcome, we found that still birth patients ( p value = 0.012), early neonatal death ( p value = 0.026), perinatal death ( P value = 0.0003), low birth weight babies ( p value = 0.016) and NICU admission ( p value = 0.0018) are significantly associated with severe maternal outcome.

19. Eclampsia causes different organ system dysfunctions, neurological system (30.66%) is most commonly involved followed by respiratory system (24%), hematological (18.67%), cardiological (16%), hepatological (10.66%) and uterine system dysfunction (5.33%) (Table  4 ). A total of 229 eclampsia patients studied in our study, we got 81 severe maternal outcome, 75 maternal near miss and six maternal deaths (Fig.  2 ). A total number of live births were 15,272. We calculated various maternal indices from our study. We got SMOR 5.30 per 1000 live births, MNMR 4.91 per 1000 live births, maternal near-miss mortality ratio (MNM:1MD) 12.5:1 and mortality index 7.40. The causes of maternal death are shown in Table  5 .

20. Discussion : To the best of our knowledge, this is the fi rst study to document maternal near miss and maternal death in eclampsia using the WHO near-miss criteria in a tertiary care hospital in eastern India and among few studies conducted in India. In our study, the incidence of eclampsia is 1.22%. Eclampsia occurred in both extremes of age group in reproductive women. The maximum (54%) belongs to 15–19 years with a mean age of 20.27 years. The mean age of women with eclampsia having severe maternal outcome is 20.23 years similar to study findings of Kedar et al. [ 6 ].

21. The significant difference observed in the incidence of eclampsia among the very young and primigravida (82%) compared to multigravida, and most of the patients having severe maternal outcome (61%) had preterm gestation similar to study done by Zanette et al. [ 7 ] where 69% of severe maternal outcome patients had preterm babies. Among all patients in our study population, 57% belong to lower socioeconomic status, and 83% of patients visited irregularly to ANC and developed severe maternal outcome.

22. Most women who suffered from eclampsia were less than 20 years of age (54%), primigravida (82%), low socioeconomic condition (58%) and without adequate antenatal care (69%). These findings recommend that the most appropriate interventions and strategies to optimize the outcome of eclampsia should be interventions aiming to improve com munity monitoring and overcome barriers to accessing care may be by most appropriate use of resources. About 70% of severe maternal group were referred from other referral centers which suggests delay in reaching to our facility from other centers. Many women with severe maternal condition come with organ dysfunction in eclampsia, which reflect poor referral system and delays in achieving appropriate health care. Health workers in different health centers should be properly trained for initial management, timely referral and prophylactic use of magnesium sulfate to prevent near miss events .

23. Severe maternal outcome in our study was significantly associated with irregular antenatal visit, poor referral system, urinary protein ≥ 2 + , patients came with altered sensorium and patients having ≥ 3 convulsions on arrival to hospital and convulsion to MgSO4 start interval > 6–12 h. It is similar to the findings of study done by Manyahi et al., Tura et al. and Adamu et al. [ 8 – 10 ]. In our study, maternal mortality was 2.67% which is simi lar to the study done by De Barros et al., Drechsel et al. and Mahran et al. [ 11 – 13 ]. Maternal mortality has shown a slight reducing trend from 14.12% in 1982 to 2.2–9% in 2010, thanks to the use of MgSo4 in all eclamptic women along with improved treatment protocol and good facility of ICU management in tertiary level hospital in recent years [ 2 ].

24. In our study, we got maternal near miss as 32.75% and severe maternal outcome as 35.37%. Maternal near- missratio (MNMR) was 4.91 per 1000 live births, and severe maternal outcome ratio (SMOR) was 5.30 per 1000 live births. The result of the present study is in accordance with the study done by Zanette et al. [ 7 ] where we got MNMR as 4.2 per 1000 live births. Incidence or prevalence of near-miss cases shows a wide variation due to regional variations, diff erent set up facilities and due to different criteria used for near-miss case identifi cations. In our study, maternal near miss—mortality ratio was 12.5:1 which means in every twelve women with life-threatening complication, one woman died, and mortality index was 7.4 which means that life-threatening complication was often deadly even when the women received standard care.

25. About 70% of near-miss women and all women who died were referred from peripheral hospitals. These results are consistent with most studies in developing countries, which have shown that the majority of patients are admit ted to hospitals in a critical condition, thus suggesting that there is a delay in reaching adequate medical assistance. Concerning the distribution of MNM events, neurologi cal dysfunction was found to be associated with major ity (30.66%) of cases followed by respiratory dysfunction (24%), hematological dysfunction (18%), cardiovascular dysfunction (16%), hepatological dysfunction (10.66%), renal dysfunction (9.33%) and uterine dysfunction(5.33%), similar type of result found in Adamu et al. and De Barros et al. [ 10 , 11 ].

26. In women with eclampsia, there is concern for fetal well-being of the potential risk of fetal distress and fetal death due to placental dysfunction. In the study across ten middle- and low-income countries on women with eclampsia, the overall rate of stillbirth or neonatal mortality in eclampsia varied between 4.1 and 23.1% with overall perinatal mortality of 15.9% [ 14 ]. In our study, we had 24 (10.49%) still birth. Still birth rate increased in case of severe maternal outcome patients (17.28%). Early neonatal death was 16.15% among eclamptic patients, and in severe maternal group, it was increased to 23.45%

27. Perinatal death among all eclamptic patients 26.63–0.40% of babies among severe maternal outcome group had perinatal mortality. About 45% of babies admitted in NICU. Respiratory distress syndrome due to prematurity was the main cause of NICU admission. About 43% of babies were low birth weight among all eclampsia patients, and 59.6% of severe maternal group had low birth weight which is similar to study done by Drechsel et al. and Barbosa et al. [ 12 , 15 ].

28. Our study has several strengths and limitations. The strengths of our study were the rigorous method of pro spective data collection, no previous study available on such a large sample size, the WHO near-miss criteria applied on all study participants. And limitations are as it is a single-center study, study population is restricted to a specific area. Follow-up of study participants after discharge from hospital was not done.

29. Maternal near miss and maternal death were frequent among women suff ered from eclampsia. The study shows that there is a scope to improve antenatal care and uti lization of other health facilities for prevention and treatment of women with eclampsia Early diagnosis of preeclampsia, good perinatal supervision can prevent eclampsia to large extent and appropriate treatment can ameliorate many cases so that maternal and fetal outcome is satisfactory .