Near miss

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NEHARIKA'S PAPER AT AICOG MUMBAI

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Near miss

  1. 1.  Despite therapeutic advances during this century and a growing perception of the safety of child birth, morbidity and mortality continue to occur in obstetric patients. More than one woman dies every TEN minute from such causes. In addition to maternal death, women experience more than 50 million maternal health problems annualiy. As many as 300 million women-more than one quarter of all adult women living in the developing world currently suffer from short or Iong term illness and injuries related to pregnancy and child birth. For every maternal death there are many serious life threatening complications of pregnancy. Yet relatively little attention has been given to identifying a general category of morbidity that could be called near-misses
  2. 2.  The analysis of maternal deaths has long been used for the evaluation of women’’s ealth and the qualityof obstetric care h Over the last decade, the identification of cases of severe maternal morbidity has emerged as a promising complement or alternative to the investigation of maternal deathS. It has been suggested that with the observed decline in maternal mortality, analysis of well defined near-miss cases may be a more sensitive measure of the standard of obstetric care. Incorporation of near-misses into maternal death enquiries would strengthen these audits by allowing for more rapid reporting; more robust conclusions, comparisons to be made with maternal deaths, reinforcing lessons learnt, establishing requirement for intensive care and calculating comparative indices
  3. 3. WHATS A NEAR MISS? Every woman can experience sudden and unexpected complications during pregnancy, child birth and just after delivery. Morbidity during pregnancy represents part of a continuum between extremes of good health and death. On this continuum a pregnancy may be thought of as being uncomplicated, complicated, severely complicated or life threatening
  4. 4.  Near Miss Maternal Mortality is a term which is very difficult to define.Any pregnant women or recently delivered women within 6 weeks of delivery or termination of pregnancy in whom immediate survival is threatened and who survives by the medical intervention and hospital care can be termed as Near Miss By Mantel GD et al, a near miss describes a patient with acute organ system dysfunction, which if not treated appropriately, could result in death. Prual A et al, has defined severe maternal morbidity as severe complications from 28th week of gestation to 42nd day postpartum that would have resulted in death of the mother or a definite invalidating sequelae without medical intervention.
  5. 5.  In different studies, the primary obstetric causes of severe maternal morbidities have been found to be hypertensive disorders of pregnancy, massive obstetric haemorrhage. Obstructed labour has been found to be an important cause in some studies.
  6. 6. Risk factorsThe risk factors of severe maternal morbidites have been identified as: Maternal age >34 social exclusion Hypertension, Previous PPH Delivery by emergency caesarean section, Multiple pregnancy Anaemia Low status of women who do not attend antenatal care in a given health unit but are referred there when they develop life-threatening obstetric complications, contribute significantly to maternal morbidity. Induced abortions conducted by untrained village midwife (DAI) is still a major cause of morbidity in the developing countries
  7. 7. MATERIAL AND METHODS 222 potentially Life threatening cases were studied in a private hospital (Malhotra Nursing Home) in Agra(INDIA) in past five years . And we did a comparison with a rural hospital where we found out about 1080 potentially life threatening cases in past three years. The main outcome measures were: rate of near miss and its primary determinant factors, criteria for its identification, total hospital stay, ICU stay, and number and kind of special procedures performed. Complete statistical Analysis was done related to the causes and preventive measures and hospital recovery stay in the study.
  8. 8. OUR STATISTICSTOTAL NUMBER Private hospital Rural HospitalOF DELIVERIES (Five years) (Three years)(PAST 5 YRS)NO OF LIVE BIRTHS 1909 6480NO OF NEAR MISS 32 482NO OF MATERNAL 0 9DEATHSNO OF LIVE BIRTHS 19 250IN NEAR MISS
  9. 9. Private Hospital 32 1.67%
  10. 10. Rural Hospital 278 482 287 6480 (7.4%) 4.29%MATERNAL MORTALITY- 9
  11. 11. POSSIBLY LIFE RURAL HOSP % PRIVATE %THREATENING N= 1080 N=222CASESPRE- 391 36.5% 122 54.5%ECLAMPSIA/HELLPHAMEORRHA 270 25% 34 15.3%GEABRUPTIO 100 10.8% 14 6.3%THROMBOCY 78 7.2% 15 6.7%TOPENIAINFECTION/SE 154 14.2% 8 3.6%PSISCHD 17 1.5% 8 3.6%PULMONARY 19 1.7% 5 2.2%OEDEMASICKLE CELL 21 2.0% 4 1.8%JAUNDICE/DIC 30 2.7% 4 1.8%
  12. 12. NEAR MISS CASES N =32(private) % N=287(rural) %INTUBATION AND 16 49% 87 31%VENTILATIONCLOTTING FAILURE 10 32.2% 30 10.4%BLOOD 8 25.8% 56 19.51%TRANSFUSIONS>5UNITSTHROMBOCYTOPENI 7 22.6% 23 8.2%AHYSTERECTOMY 4 12.9% 17 5.9%RE-EXPLORATION 3 9.7% 29 11%DIALYSIS 1 3.22% 4 1.3%SHOCK 6 19.3% 21 7.3%BILIRUBIN>6mg/dl 4 12.9% 20 7%
  13. 13. MATERNAL MORTALITY 0 IN PRIVATE MATERNALMORTALITY IN 9 RURAL
  14. 14. CONCLUSION Efforts geared towards improvement in the management of near-miss morbidities would definitely go a long way in reducing the present maternal mortality ratio. From the findings of this review, attempts to reduce maternal deaths may best be achieved by developing evidence-based protocols for the management of severe hypertension and haemorrhage especially for critically ill referred patients. In addition, considerable efforts should be made to improve maternal care for infrequent but important life-threatening obstetric conditions such as uterine rupture and infection. Necessary facilities should be made available and training of personnel and emergency drills should be frequently conducted to combat the identified disease processes that received suboptimal care. Although this study did not specifically address avoidable factors, it has nevertheless raised awareness of the deficiencies in the management of serious maternal illnesses

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