Tephinet sudafrica 2010

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Presentación en Ciudad del Cabo, Sudáfrica, diciembre2010

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  • In the reference units that have intensive patient at death is not recorded as maternal death and the case is lost. This is ninety-five percent of the time. NEXT SLIDE
  • The reasons for transfer were hypertensive pictures unstable and severe hypovolemic shock. NEXT SLIDE
  • Tephinet sudafrica 2010

    1. 1. Extreme Maternal Morbidity and Maternal Mortality Reduction by Implementing a Surveillance System at the Gynecology and Obstetrics Hospital, Guatemala 2007-2009 Dr. Jorge David Alvarado Andrade FETP 2008 (Intermediate Level) Gynecology and Obstetrics Hospital, Social Security Institute
    2. 2. Maternal Mortality in Guatemala <ul><li>Guatemala </li></ul><ul><ul><li>12,000.000 habitants </li></ul></ul><ul><ul><li>Annual LB: 369, 769 (2008) </li></ul></ul><ul><ul><ul><li>51% attended by health workers </li></ul></ul></ul><ul><ul><li>MMR: 153/100,000 LB </li></ul></ul><ul><li>Social Security (IGSS) </li></ul><ul><ul><li>Attend the 8% de LB </li></ul></ul><ul><ul><li>Gynecology and Obstetric Hospital (GOH) </li></ul></ul><ul><ul><ul><li>Third level hospital </li></ul></ul></ul><ul><ul><ul><li>Annual attend LB: </li></ul></ul></ul><ul><ul><ul><li>16,000 (90% of IGSS) </li></ul></ul></ul>
    3. 3. Background <ul><li>In 2007, IGSS reported 42 cases of confirmed maternal deaths, of which only 1 occurred in the GOH. </li></ul><ul><li>No cases of obstetric patients with extreme maternal morbidity (Near-Miss) </li></ul><ul><li>Real or underreporting? </li></ul>
    4. 4. How death was registered? Maternal Deaths Hospital Maternal Deaths Records Floor Supervisor or Ward Supervisor Nursing Supervisor Statistical Service This occurred in 5% (2 / 42) of the cases
    5. 5. How Near-Miss was registered? (II) Extreme Maternal Morbidity (GOH) Transferred to another unit of IGSS (Intensive Care) Dead Admitted in the Transfer Unit Hospital Discharge Alive Statistical Service at the Transfer Unit Happened in 95% (40/42) of cases
    6. 6. Objectives <ul><li>Design and implementation of an improved Maternal Mortality Surveillance System (MMSS) based in GOH. </li></ul><ul><li>Identify all cases of Maternal Mortality (MM) and Extreme Maternal Morbidity (EMM) that occur in the GOH (2009) and determine their causes </li></ul>
    7. 7. Phases of Development of the MMSS <ul><li>Diagnosis the situation the MM (2007) </li></ul><ul><li>Create the SSMM Committee (2008) </li></ul><ul><ul><li>a. Development of the Protocol </li></ul></ul><ul><ul><li>b. Restructuring the System for EMM and MM cases recording </li></ul></ul><ul><li>Active surveillance (2009) </li></ul>
    8. 8. Results Current Reporting System EMM and MM Surveillance Committee Analysis of Cases and Drafting Conclusions and Recommendations Results Dissemination Maternal Deaths Hospital Maternal Deaths Records Floor Supervisor or Ward Supervisor Nursing Supervisor Statistical Unit
    9. 9. Current Reporting System (II) Chief resident and / or residents III Referral Notification EMM and MM Surveillance Committee Case Analysis and Drafting Conclusions and Recommendations Results Dissemination Feedback Extreme Maternal Morbidity (HGO) Transferred to another unit of IGSS (Intensive Care) Dead admitted in the transfer unit Hospital Discharge Alive Statistical Service at the Transfer Unit
    10. 10. Data Analyzer
    11. 11. Overview of EMM population treated at the GOH Guatemala, 2009 n = 363 Parity No. of Cases % Primigravida 1 0 Secundigesta 111 31 Multiparous 183 50 No data available 68 19 Timing at Complication % Miscarriage 62 17 Preterm 124 34 Term 103 28 Prolonged 5 1 No data 4 1 Puerperium 65 18 Procedure % Caesarea 274 75 Delivery 23 6 Curettage 8 2 Other 55 15 No data 3 1
    12. 12. Top ten causes of EMM in patients treated at the GOH Guatemala, 2009 Source: Book of deliveries, cesarean sections and reports from team leaders n = 363 Morbility No. of Cases % Severe Hypertension 110 30 Ectopic Pregnancy 50 14 Pre-eclampsia / Eclampsia 49 13 Acute Abdomen 28 08 Placenta Previa Bleeding 25 07 HELLP Syndrome 19 06 Fetal Distress 18 05 Failed Induction 12 03 Placenta Accreta 11 03 Uterine Atony 8 02 Other Causes 33 09 TOTAL 363 100
    13. 13. Top ten reasons for transfer patients treated with EMM to ICU from GOH. Guatemala, 2009 Source: Book of deliveries, cesarean sections and reports from team leaders n = 50 Transfer Causes No. of Cases % Unstable Hypertension 18 36 Hypovolemic Shock 11 22 Septic Abortion 1 02 Eclampsia 1 02 Respiratory Failure 1 02 Granulocytic Leukemia 1 02 HELLP Syndrome 1 02 Metabolic Disorder 1 02 Inmunological Disease 1 02 PostPartum Hemorrage 1 02 Other Causes 13 26 TOTAL 50 100
    14. 14. Place of transfer to intensive care for patients treated with EMM at GOH Guatemala, 2009. Source: Book of deliveries, cesarean sections and reports from team leaders Transfer Unit No. of Cases % Gynecology and Obstetrics Hospital 312 87.05 Intensive A 39 10.74 Intensive B 10 02.75 Infeccions Floor 1 00.28 **No data 1 00.28 TOTAL 363 100.00 Transfer to Intensive 50
    15. 15. Maternal Mortality Ratio at the GOH Guatemala, 2007 to 2009 Cases Maternal Mortality Ratio *Absolute number of maternal deaths were 11(2009), 7(2008) and 4(2010) n = 22 Years
    16. 16. Causes of MM at the GOH Guatemala, 2007 to 2009 n = 22 2007 2008 2009 Cause of Death Cases % Cases % Cases % Hipertensive Status 2 18 3 43 1 25 Postpartum Hemorrage 3 27 2 29 1 25 Septic Abortion 5 45 1 14 1 25 Medical Complications 1 9 1 14 1 25 TOTAL 11 100 7 100 4 100
    17. 17. Impact to Public Health Relationship between Maternal Mortality Ratio and Audit of cases at the GOH, Guatemala 2007 to 2009 Percentage Years Maternal Mortality Ratio Audit Cases
    18. 18. Limitations of SSMM <ul><li>Resistance to notify cases </li></ul><ul><li>Lack of enforcement by IGSS of the new regulations for surveillance of MM </li></ul><ul><li>Misclassification of maternal deaths </li></ul><ul><li>Incomplete and/or inappropriate comicent of the reporting forms </li></ul>
    19. 19. Achievements in 2010 <ul><li>Audit of 92% of the cases of EMM and MM </li></ul><ul><li>Risk factors for MM are being analyze </li></ul><ul><li>System Surveillance delays are being evaluated </li></ul><ul><li>Construction of the ICU in GOH </li></ul><ul><li>Social Work Service was incorporated in to the MMSS as another source of reporting </li></ul>
    20. 20. Thanks for your attention LakeAtitlàn Guatemala
    21. 21. Methods Years 2007 2008 2009 Conventional Statistical Record Form the surveillance committee Protocol Development and Implementation Review of Cases occurred in 2007 Monitor and Audit Cases occurred in 2008 Active Surveillance of MM and MME cases Audit Cases of MM and EMM Development and Dissemination of Reports Implementation of Control Measures
    22. 22. Activities <ul><li>Create the Surveillance Committee for Maternal Mortality and Extreme Maternal Morbidity (2008) </li></ul><ul><li>Development of the Protocol: </li></ul><ul><ul><li>Data Source </li></ul></ul><ul><ul><li>Notification Process (define scenarios) </li></ul></ul><ul><ul><li>Frequency of Notification </li></ul></ul><ul><ul><li>Operational Definitions </li></ul></ul><ul><ul><li>Inclusion and Exclusion Criteria </li></ul></ul><ul><ul><li>Type of surveillance </li></ul></ul>
    23. 23. <ul><li>Data Analysis: </li></ul><ul><ul><li>Classify the deaths as maternal or not maternal related </li></ul></ul><ul><ul><li>Determine if MM were preventable </li></ul></ul><ul><ul><li>Explore the major risk factors </li></ul></ul><ul><li>Analyze and interpret results </li></ul><ul><li>Present and discuss the results </li></ul><ul><li>Restructuring the system for EMM and MM cases recording </li></ul>Activities (II)
    24. 24. Discharge status of patients with EMM attended at GOH, Guatemala, 2009. Source: Book of deliveries, cesarean sections and reports from team leaders Condition at Discharge No. of Cases % Alive 359 98 Dead 4 2 TOTAL 363 100 Maternal Mortality Ratio: 26.4 *100.000 live births (4 deaths/15,161 births*100,000) Reason of nears-miss: 4/363 * 100 =1,1 (1 per 100)

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