BackgroundInvestigating severe maternal morbidity (near-miss) is a newly recognised tool that identifies women at highest risk of maternal death and helps allocate resources especially in low income countries. This study aims to i. document the frequency and nature of maternal near-miss at hospital level in Damascus, Capital of Syria, ii. evaluate the level of care at maternal life-saving emergency services by comparatively analysing near-misses and maternal mortalities.MethodsRetrospective facility-based review of cases of near-miss and maternal mortality that took place in the years 2006-2007 at Damascus Maternity University Hospital, Syria. Near-miss cases were defined based on disease-specific criteria (Filippi 2005) including: haemorrhage, hypertensive disorders in pregnancy, dystocia, infection and anaemia. Main outcomes included maternal mortality ratio (MMR), maternal near miss ratio (MNMR), mortality indices and proportion of near-miss cases and mortality cases to hospital admissions.ResultsThere were 28 025 deliveries, 15 maternal deaths and 901 near-miss cases. The study showed a MNMR of 32.9/1000 live births, a MMR of 54.8/100 000 live births and a relatively low mortality index of 1.7%. Hypertensive disorders (52%) and haemorrhage (34%) were the top causes of near-misses. Late pregnancy haemorrhage was the leading cause of maternal mortality (60%) while sepsis had the highest mortality index (7.4%). Most cases (93%) were referred in critical conditions from other facilities; namely traditional birth attendants homes (67%), primary (5%) and secondary (10%) healthcare unites and private practices (11%). 26% of near-miss cases were admitted to Intensive Care Unit (ICU).ConclusionNear-miss analyses provide valuable information on obstetric care. The study highlights the need to improve antenatal care which would help early identification of high risk pregnancies. It also emphasises the importance of both: developing protocols to prevent/manage post-partum haemorrhage and training health care professionals to manage infrequent but fatal conditions like sepsis. An urgent review of the referral system and the emergency obstetric care in Syria is highly recommended.

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Background. Video-EEG (VEEG) monitoring is a vital diagnostic tool, but there are no guidelines for withdrawal of antiepileptic drugs (AEDs). Aim. The main objectives of this study were to understand the different withdrawal strategies used in the EMU, how strategies are chosen, and the efficacy and safety of different withdrawal strategies in producing seizures. Materials and methods. We retrospectively analyzed 95 consecutive patients and measured time to first seizure, incidence of status epilepticus, and need for rescue medications. Results. We found that AED withdrawal strategies can be divided into four categories based on level of aggressiveness. The main factors which impacted choice of strategy was number of AEDs on admission and frequency of pre-admission seizures. Abrupt cessation of medications was correlated with longer time to first seizure compared to other methods (hazard ratio (HR) 0.36, 95% confidence interval (CI) 0.20-0.65, p = 0.0007). Patients remaining on medications had shorter time to first seizure (HR 2.98, 95% CI 1.22-7.24, p = 0.016). Withdrawal technique was not correlated with need for rescue medications (OR 5.0, 95% CI 0.77-43, p = 0.20). No patients had status epilepticus in the study. Conclusions. Pre-admission seizure frequency and number of AEDs are the main factors which drive choice of withdrawal strategy on the epilepsy monitoring unit (EMU). Counterintuitively, least aggressive strategy is associated with highest risk of seizures. Results of this analysis suggest that disease factors, not choice of withdrawal strategy, determine seizure frequency on the EMU.

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