Preventability review of severe maternal morbidity

Lawton, Beverley; MacDonald, Evelyn Jane; Stanley, James; Daniells, Karen; Geller, Stacie E.

doi:10.1111/aogs.13526

Cited by 33 publications

(47 citation statements)

References 23 publications

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“…In reviewing the 31 cases of near miss, ten were viewed to have some aspect of provider/system related factor contributing the severe morbidity. This is in keeping with previous studies utilising Geller's preventability model which have shown that about one-third of cases have some level of provider or system related preventability 7,13,14 . Most cases of provider related preventability relate to lack of diagnosis/recognition of decompensation, followed by the lack of ability to undertake the appropriate procedures in a timely fashion.…”

Section: Discussionsupporting

confidence: 90%

“…Additionally, our preventability review was an internal review subject to bias -external review using trained multidisciplinary cohort of staff may provide a more objective assessment of preventabilitythis has been successfully undertaken in various local and national settings in New Zealand (NZ) but requires further validation in the Australian setting 7,13,14 Conclusion This is the first study to characterise obstetric ICU patients in a regional Australian setting and overall maternal morbidity and obstetric ICU admission rates are reassuringly low. Obstetric haemorrhage and hypertensive disorders of pregnancy are the most common diagnoses for admission, although many cases are admitted for more intensive monitoring rather than for specific interventions.…”

Section: Discussionmentioning

confidence: 99%

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Characteristics and preventability of Obstetric ICU admissions in Far North Queensland

Jayaratnam¹,

Jacob-Rodgers²,

deCosta³

2019

Preprint

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Background The rarity of maternal deaths in developed countries has increased interest in reviewing cases of severe maternal morbidity or maternal ‘near miss’. Assessment and determining preventability among near misses is therefore important in improving the provision of maternity care. The aims of this study were to (i) describe the epidemiology of intensive care unit (ICU) admission in Far North Queensland (ii) determine the validity of the WHO near miss criteria in determining cases of severe maternal morbidity and (iii) determining preventability of severe maternal outcomes of pregnant and post-partum patients requiring admission to the ICU. Methods Retrospective observational study included all patients pregnant or within 42 days of termination of pregnancy admitted to the Cairns Hospital ICU between 1st January 2013 and 31 December 2017. Cases were reviewed by a team of Obstetricians using the modified Geller model of preventability to determine reasons for admission to ICU and to determine whether the ‘near miss’ was preventable or not.Results Sixty-nine out of 12081 (0.6%) women admitted for Obstetric care were transferred to the ICU with a total of 31 cases fulfilled WHO near miss criteria. The most common primary obstetric related diagnosis for ICU admission were hypertensive disease of pregnancy and obstetric haemorrhage. Indirect obstetric causes contributed to approximately 40% of ICU admissions. Among the 31 cases of WHO near miss, 10 cases were deemed preventable with the most common reason for preventability related to lack of recognition of high-risk clinical status. Conclusion Maternal ‘near miss’ and rates of Obstetric admission to the ICU at Cairns Hospital are reassuringly low. An audit of near miss cases describing preventability is feasible and informs areas for improvement in the management of ‘near miss’ cases.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Characteristics and preventability of Obstetric ICU admissions in Far North Queensland

Jayaratnam¹,

Jacob-Rodgers²,

deCosta³

2019

Preprint

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“…A recent review in New Zealand showed that at least onethird of SMM cases may be preventable, 29 and other studies have observed a high proportion of SMM due to obstetric haemorrhage. 13,17,30,31 It follows that the alleviation of anaemia in early-or mid-pregnancy might reduce both transfusion and SMMespecially those SMM elements more plausibly linked to a low haemoglobin ( Figure S1).…”

Section: Discussionmentioning

confidence: 98%

Haemoglobin levels in early pregnancy and severe maternal morbidity: population‐based cohort study

Ray

Davidson

Berger

et al. 2020

BJOG

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Objective Data regarding low maternal haemoglobin concentration and severe maternal morbidity (SMM) are limited and potentially biased. This study evaluated the relation between early maternal haemoglobin concentration and SMM or maternal mortality. Design Population-based cohort study. Setting Ontario, Canada, in a public healthcare system. Population 737 393 births with a routine outpatient haemoglobin measured at a calculated gestational age of 2-16 weeks. Methods The relation between early-pregnancy outpatient blood haemoglobin concentration and each study outcome was expressed as adjusted relative risks (aRR) and absolute risk differences (aRD), with 95% confidence intervals (CI), generated by modified Poisson regression. Main outcome measures The primary outcome was SMM or maternal mortality, from 23 weeks' gestation to 42 days postpartum. Results The mean (SD) haemoglobin concentration was 126.9 (9.3) g/l. Overall, SMM or death occurred in 13 514 pregnancies (1.8%). Relative to a haemoglobin level of 125-129 g/l, the aRR was 1.07 (95% CI 1.02-1.13) and aRD (0.09%, 95% CI 0.01-0.18) at 120-124 g/l; aRR 1.31 (95% CI 1.17-1.46) and aRD 0.47% (95% CI 0.24-0.69) at 105-109 g/l; and aRR 4.53 (95% CI 3.59-5.72) and aRD 5.94% (95% CI 4.12-7.76) at <90 g/l. In all, 5961 women (0.8%) required red cell transfusion, with significantly higher risks at all haemoglobin concentrations below 125-129 g/l, peaking at a haemoglobin level <90 g/l (aRR 11.82, 95% CI 9.30-15.03). Conclusion There is a gradual increase in the risk of SMM or death, as well as red cell transfusion, starting from the lower level of the normal range of haemoglobin of non-pregnant women.

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“…This is a national retrospective cohort study of SMM cases in A SMM case was defined as any woman admitted to an Intensive Care Unit (ICU) or High Dependency Unit (HDU) during pregnancy, up to six weeks postpartum. 6 ICU admission has 79-86% sensitivity and 88-95% specificity for a SMM event and identifies about 30% of SMM cases and usually the most severe. [11][12][13] Adverse fetal/ neonatal outcomes were defined as one or more of the following: death (miscarriage, abortion, fetal death, or neonatal death), hypoxic ischaemic encephalopathy (HIE), Apgar score less than seven at five minutes, and/or, admission to a Neonatal Intensive Care Unit (NICU) or SCBU.…”

Section: Methodsmentioning

confidence: 99%

Examining adverse fetal/neonatal outcomes associated with severe maternal morbidity

Lawton

Filoche

MacDonald

et al. 2020

Aust NZ J Obst Gynaeco

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Background: While there is a global focus on severe maternal morbidity (SMM), less is known about the impact of SMM on fetal and neonatal outcomes. Aims: To examine fetal/neonatal outcomes associated with SMM. Materials and Methods: A national New Zealand (NZ) retrospective cohort study describing fetal/neonatal outcomes of all women with SMM admitted to a NZ Intensive Care Unit (ICU) or High Dependency Unit (HDU) in 2014. Adverse fetal/ neonatal outcomes were defined as one or more of the following: fetal or early neonatal death, hypoxic ischaemic encephalopathy, Apgar score less than seven at five minutes, admission to Neonatal Intensive Care Unit or Special Care Baby Unit. Results: There were 400 women with SMM admitted to NZ ICU/HDU units in 2014, and 395 (98.8%) had complete birth/pregnancy outcome information. Of these, 49.4% (195/395) were associated with an adverse fetal/neonatal outcome. Indigenous Māori women had a 30% higher rate of adverse fetal/neonatal outcome compared to NZ European women (63.7% and 48.9% respectively; relative risk = 1.30, 95% CI 1.04-1.64). Pre-eclampsia was associated with an adverse fetal/ neonatal outcome in 67% (81/120). Perinatal-related mortality rate was 53.1 per 1000 total births compared to NZ perinatal mortality of 11.2 per 1000 total births for 2014. Conclusion: SMM events are associated with high rates of adverse fetal/neonatal outcomes with a higher burden of adverse events for Māori. Further research is needed to explore opportunities in maternal and neonatal care pathways to improve fetal/neonatal outcomes and address inequities. K E Y W O R D S ethnic disparities, fetal/neonatal outcomes, severe maternal morbidity BACKGROUND Globally, it is estimated that severe maternal morbidity (SMM) occurs in approximately 1-2% of pregnancies with a greater incidence in minority populations. 1-4 It is estimated that approximately 30-40% of these severe events are potentially preventable. 5-7 SMM or maternal near-miss are terms used to identify women with life-threatening complications in pregnancy. The World Health Organization (WHO) defines this severe end of the morbidity spectrum as 'the near death of a woman who has survived a

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Preventability review of severe maternal morbidity

Cited by 33 publications

References 23 publications

Characteristics and preventability of Obstetric ICU admissions in Far North Queensland

Characteristics and preventability of Obstetric ICU admissions in Far North Queensland

Haemoglobin levels in early pregnancy and severe maternal morbidity: population‐based cohort study

Examining adverse fetal/neonatal outcomes associated with severe maternal morbidity

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