Severe Acute Maternal Morbidity Arulmozhi Ramarajan
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1SEVERE ACUTE MATERNAL MORBIDITY
2SEVERE ACUTE MATERNAL MORBIDITY
Arulmozhi Ramarajan MD DGO PGDMLE Head of the Department of Obstetrics and Gynecology Church of South India Hospital, Bengaluru Past President, Bangalore Society of Obstetrics and Gynecology Bengaluru, Karnataka, India
3Published by
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Severe Acute Maternal Morbidity
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4
“Maternal mortality is not statistics. It is not numbers. It is not rates or ratios. Maternal mortality is people. It is women, women who have names, women who have faces and we have seen these faces in the throes of agony, distress and despair. They are faces that continue to live in our memory and haunt our dreams. This is not simply because these are women who die in the prime of their lives, at a time of great expectation and joy. And it is not simply because a maternal death is one of the most terrible ways to die, be it bleeding to death, the convulsions of toxemia of pregnancy, the unbearable pangs of obstructed labor, or the agony of puerperal sepsis. It is because in almost each and every case, in retrospect, it is an event that could have been prevented. It is an event that should never have been allowed to happen. It is an event that bears and should bear so heavily on our collective conscience.”
Dr Mahmoud Fathalla
World Health Day, April 7, 1998.
5CONTRIBUTING AUTHORS
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8FOREWORD
Severe acute maternal morbidity (SAMM) is the acronym for the more popular term of ‘near-miss’ cases. Technically, SAMM may sound better as it incorporates words like acute and morbidity, but the term ‘near miss’ seems to convey the meaning better. This term, borrowed from the airline industry, more correctly conveys the gravity of the situation and the urgency it demands. Auditing such events is considered the next best way after confidential review of maternal deaths, to know about the standard of obstetric care. Indirectly, maternal mortality ratio of a population is the yardstick of social development and equity. But, for the countries which have achieved very low figures of maternal mortality, audit of near misses will provide the opportunity to assess the standard of care.
Deciding on criteria to identify the near misses is not easy. Every branch of medicine has cases or events which can suddenly and unexpectedly slip to become a catastrophe. Unfortunately, obstetrics has a major share of such cases. Putting down inclusion and exclusion criteria to identify such cases is clinically impossible. Still a working definition is required. “A severe life-threatening obstetric complication necessitating an urgent medical intervention in order to prevent the likely death of the mother” is a good one. However, when one tries to allot real-life situations to near-miss category, there will be uncertainties. Maternal death audit, on the other hand, has a definite inclusion criterion, namely, maternal death. It is unfortunate irony that some of the cases which fall under near misses, because they could be brought to life by intervention, are worse maternal deaths. The survivors in these situations exist as vegetables, devoid of brain function, but with the rest of the organ systems continuing to work and as a burden to the family and the society.
The examples, which are real-life situations, described in the various chapters of this book help the reader realize how easily apparently normal cases can suddenly slip into dangerous situations. The examples also help to emphasize the need for following standard protocols and procedures in the management. The case of postpartum hemorrhage (PPH) due to the bleeder at the apex of episiotomy wound is a typical case in point. The examples in the chapter on anesthesiology illustrate how treacherous an obstetric patient can be to the anesthetist and how easily in the span of few minutes an apparently normal case can slip into maternal death.
One of the drawbacks of near-miss audit (SAMM) is its unsuitability to community obstetric cases. But institutional deliveries are on the increase and some states like Kerala and Tamil Nadu have achieved near hundred percent institutional deliveries. Other states are actually pursuing this goal. The Janani Suraksha Yojana scheme of financial incentives to institutional deliveries has attracted many more pregnant women to institutions all over the country. Just getting the patient to deliver in the institution alone will not achieve the desired benefit unless quality service is provided there. On the other hand, it can be counter-productive and take away the society's trust in institutional deliveries. This book with the many real-life situations is a timely addition to the obstetric literature and will certainly help to improve the obstetric care in the institutions. It is a must-read for all categories of obstetric care providers—doctors, nurses, midwives, nursing assistants 9and hospital administrators. Lessons can be extracted from these examples to increase patient and community awareness regarding the challenges the obstetric team faces. I would like to congratulate Dr Arulmozhi Ramarajan for bringing together the obstetricians and allied specialists to share their experience with real-life examples.
 
Dr VP Paily
State Coordinator
Confidential Review of Maternal Deaths
Kerala, India
10MESSAGE
Maternal Health Care: A Human Rights Perspective
This publication is a splendid editorial effort of a reputed gynecologist on the topic of maternal morbidity and is an impressive addition to the array of extant literature on an important area of public health and human rights.
In the preface, the author asks:
“Why mothers die is a disturbing question that has defied a definitive answer. We all agree that a woman should not die, giving life. We know that the major direct causes of maternal mortality—hemorrhage, hypertension, infection and obstructed labor—are largely preventable. We also know that for every mother dies, 20 to 30 more suffer severe disease and disability. These women ‘managed’ to live through their ordeal—to tell us their story and teach us to make pregnancy safer.”
There is an important civilization ‘message’ in this preventable tragedy. In a non-trivial sense, it holds up a mirror to our society and tells us what we really are. The culture of respect—respect in action and not rhetoric—for the welfare of women is a thing Indian society down the ages cannot be greatly proud of. The medical situation in the West with regard to women's welfare reflects a higher status of women in society.
Maternal anemia, low-birth weight-related neurological deficiencies of children and maternal mortality are some of the burning issues in human right discourse in the developing countries. ‘Maternal mortality’ is a collective expression for and captures a large array of health and social factors. The Bhore Committee (1946) disclosed an alarming maternal mortality rate of 2,000 per one lakh of childbirths in the pre-independence period. The Mudaliar Committee (1959) showed that through the following decade the figure, though in itself disturbing, had been brought down to 1,000 per lakh childbirths. The Mudaliar Committee attributed this decline to control of malaria.
In the West, in the UK and the US, the figures of maternal mortality rates are 8 and 11 respectively per one lakh childbirths. In India, the figures are still a reflection of the dire state of health care. By 1980, the figures had come down to 810. Today the situation, in comparative terms, has vastly changed and improved. It is 95 in Kerala, 111 in Tamil Nadu, 217 in Karnataka; while in Uttaranchal and Uttar Pradesh, it is still as high at 600 and 440 respectively. There is a wide range of variance amongst the states in India and within a state amongst different districts.
The key to the control of this wholly avoidable death and disability is the institutionalization of childbirth. The National Family Health Survey of 2006 shows that only 48.2 percent of childbirths were attended by skilled personnel and only 40.7 percent were institutional deliveries under medical supervision. Kerala and Tamil Nadu have achieved an impressive figure of 98 percent institutional deliveries. Many states have shown a sensitive response to this human issue and have brought in a number of programs to promote institutional deliveries. The ‘Janani Surakha Yojana’ of the National Rural Health Mission, the ‘Chiranjeevi Yojana’ of Gurajat, ‘Dhanvantri Yojana’ in Madhya Pradesh, ‘Sukhibhava’ in Andhra Pradesh, the ‘Delivery Hut Scheme’ in Haryana have all shown, though belatedly that governments are becoming increasingly aware of the importance of 11preventive health care and how certain simple solutions can produce magical results in health care. For instance, the use of treated bed-nets has significantly influenced the reduction of malarial death in Africa. Again children washing hands with soap before their meal has produced dramatic results in child health care in Africa. The blessings of Western medical research has greatly promoted maternal and childcare. Oxytocin discovered by Sir Henry Dale in 1909 and the development of prostaglandins by Sune K Burgestrom in 1982, have enhanced medical capacity in this field. I recall that some 15 years ago that tall, lanky Nobel laureate Dr Sune K Burgestrom visited India and Africa regularly to promote the awareness of importance of maternal health care and of the fact that maternal mortality was wholly preventable.
Unfortunately, the concept of ‘health care’ has, under the influence of the pharmaceutical industry and the increasing commercialization, suffered a change in its very basic philosophy. It is increasingly becoming ‘medical care’, the preventive aspect losing its focus and importance. In the poor countries having regard to high cost of quality medical treatment, prevention seems the only cure. In India, the health care industry is poised for high-growth. The WHO has prescribed a hospital bed-strength of 3,000 per million population. The actual position is just about a third of this standard.
I convey my congratulations and good wishes to Dr Arulmozhi Ramarajan for this noble and most useful effort in spreading the awareness of this great human mission of saving mothers' lives. It is an irony and travesty that they themselves die while bringing a new life into existence. The book will be a significant contribution to enhance the importance of this area of health care.
 
Padma Vibhushan Shri MN Venkatachaliah
Former Chief Justice of India and Former Chairman—National Human Rights Commission
12MESSAGE
This book is timely and opportune. It is a privilege to add my thoughts to the preface as a foreword. The control of obstetric mortality and morbidity is a struggle even to the most advanced medical care delivery system. Clinicians worldwide aim to provide training workshops and teaching to those who are frontline clinicians. This book has the table of contents that will enable a systematic delivery of safe care in motherhood and early neonatal care. The selection of risk factors and care management are well described. The case discussion and management are essential citation of further and key solutions. Every trainee and frontline clinician needs to obtain a copy of this book for safe practice.
 
Professor Christopher B-Lynch
Milton Keynes Hospital, UK
Inventor of the ‘B-Lynch suture’, for control of Postpartum Hemorrhage
13MESSAGE
Maternal mortality is a complex problem requiring complex responses. Nevertheless, every intervention must operate through one of the three pathways: Preventing pregnancy, preventing complications, and preventing death when obstetric complications occur. From a policy perspective, the most efficient approach to prevention of mortality is to reduce unwanted pregnancies. If a woman does not get pregnant, she will not die in pregnancy or childbirth. The major causes of maternal morbidity are infection, hemorrhage and hypertension.
The Federation of Obstetric and Gynaecological Societies of India (FOGSI) is working towards making emergency obstetric care (EMOC) a priority and use it as a starting point for a strengthened health system. The Safe Motherhood Committee, FOGSI, is working towards conducting seminars, symposiums and workshops on EMOC with emphasis on PPH, which is responsible for 27 percent of maternal mortality in India. It is important for every clinician to stay abreast of advances in the field. The importance of following evidence-based protocols cannot be over-emphasized. The review of near-miss situations will also help us to learn from the experience and this knowledge will help the policy makers, health systems and clinicians in improving maternal health care delivery.
This publication should serve as a foundation of information for the clinicians with references for more in-depth reading of various topics on near-miss situations in obstetrics.
I am happy to note that Dr Arulmozhi has focused on this subject of near-miss situations. This is the need of the hour. I am confident that this issue will go a long way in improving and minimizing the complications of this dreaded problem, which leads to maternal death.
 
Dr Sheela V Mane md
Chairperson, Safe Motherhood Committee, FOGSI
14PREFACE
Why mothers die is a disturbing question that has defied a definite answer. We all agree that a woman should not die, giving life. We know that the major direct causes of maternal mortality—hemorrhage, hypertension, infection, and obstructed labor—are largely preventable. We also know that for every mother who dies, 20 to 30 more others suffer severe disease and disability. These women ‘managed’ to live through their ordeal—to tell us their story, and teach us to make pregnancy safer.
Conceptually, morbidity during pregnancy represents part of a continuum between the extremes of good health and death. On this continuum, a pregnancy may be thought of as being uncomplicated, complicated, severely complicated or life-threatening.
Maternal health and safe motherhood are clearly more than the avoidance of maternal death. Near-miss appraisal has emerged as the new yardstick to assess the quality of health care. Analyzing near-miss cases can strengthen our understanding of the disease progression that ultimately kills the woman and thereby empower us to prevent maternal death. A prospective study on obstetric near-miss events in the Netherlands (BJOG. 2008 Jun; 115 (7):842–50) has revealed that substandard care was found in the majority of assessed cases.
Maternal death to near-miss ratio indicates that a significant proportion of critically ill patients died due to suboptimal level of care for life-threatening situations. This is referred to as the ‘case-fatality ratio’ and is a sensitive measure of the standard of obstetric care. The incidence of severe maternal morbidity ranges from 0.07% to 8.23%, the case-fatality ratio from 0.02% to 37%. It can be seen that there is a huge difference between case-fatality ratios in developed and developing countries. Reasons include delay in seeking help, lack of access to a health facility, non-availability of drugs or transport and inadequate or inappropriate intervention.
Pregnancy: Continuum between extremes of good health and death
‘Justice delayed is justice denied’—on the same lines, obstetric interventions in life-threatening situations should be available and accessible to the needy in time, to be useful. That alone will translate into smaller case-fatality ratios and register any decline in MMR.
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Case-fatality ratios in different countries
The book opens with an overview of ‘Severe acute maternal morbidity’: Incidence, issues and challenges in diagnosis, standard of care, near-miss audit, communication and medicolegal implications. The chapters that follow elaborate on specific issues relating to obstetric near misses. Near-miss situations are not far and few in actual practice; they are everyday occurrences. The case situations presented in this book bring to focus, the highly emergent and stressful nature of obstetric near misses. In each case, the management and outcome are described, followed by take-home messages—the blueprint for action.
 
Arulmozhi Ramarajan
16ACKNOWLEDGMENTS
This book is all about the complications of pregnancy that every student and practitioner of obstetrics has seen and known; the purpose of this book is to provide a quick and comprehensive “what to do, how to go about” guidance to the reader who is looking for answers to specific questions in specific situations. It is also an attempt to bring out the non-obstetric issues that need to be addressed to achieve our goal in reducing maternal morbidity and mortality.
Nothing hurts more than seeing healthy, happy women suffer or die because of pregnancy-related complications that are so very preventable. Nothing brings more satisfaction than saving a mother from such complications. The gratitude that effuses from the family of the saved mother is indescribable and that is the biggest award an obstetrician can ever receive. If the effort helps to save one more woman from the perils of pregnancy, this project will be considered worthwhile.
I am grateful to all my colleagues who have shared their professional experience and ideas for the book. Their interest and enthusiasm have been palpable. They have spared precious time to pen the chapters in the midst of their tight schedules and were open to editorial changes—all because everyone looked for a book that would enable the reader to provide better service to the women they care for. My special thanks go to Dr Susheela Rani, Professor R Narayanan, Professor Gomathy Narayanan and Dr Prakash K Mehta for their valuable suggestions and ideas at all times. I deem it a great honor to have received good wishes and encouraging words from eminent contributors to maternal health.
I express my thanks to Professor Christopher B-Lynch for his message and good wishes and for permission to use images relating to the control of postpartum hemorrhage in this book. I am deeply indebted to Padma Vibhushan Shri MN Venkatachalaiah, former Chief Justice of India and former Chairman of the National Human Rights Commission for his special message on this publication. I feel humbled and honored by his kind words. Dr VP Paily has been a source of inspiration for me in this work. I express my thanks to him for his encouraging words and his Foreword. I thank Dr Sheela V Mane, Chairperson of the FOGSI, Safe Motherhood Committee, for her message.
I thank Mr Nelson, Mr Prakash and Mrs Rashmi of Harry and Louit Advertising for their creative efforts in designing and formatting the book. I thank M/s Jaypee Brothers Medical Publishers (P) Ltd for providing me an opportunity to bring out this work.
Last but not least, I will be failing in my duty if I do not thank all those mothers—living and gone—who have taught us invaluable lessons through their sufferings. They have been our greatest teachers and this book is an effort to pass on that knowledge and experience to every reader, to save more mothers.
25ABBREVIATIONS ABG
Arterial blood gas
AFE
Amniotic fluid embolism
AMTSL
Active management of third stage of labor
APH
Antepartum hemorrhage
API
Abnormal placental invasion
APTT
Activated partial thromboplastin time
ARDS
Acute respiratory distress syndrome
ASHA
Accredited social health activist
CAOS
Chronic abruption-oligohydramnios sequence
CCT
Controlled cord traction
CFR
Case-fatality rate
CPD
Cephalopelvic disproportion
CTG
Cardiotocogram
CTPA
Computed tomography pulmonary angiogram
CVP
Central venous pressure
DIC
Disseminated intravascular coagulation
DVT
Deep vein thrombosis
ECG
Electrocardiogram
EFM
Electronic fetal monitoring
EMOC
Emergency obstetric care
FFP
Fresh-frozen plasma
FGR
Fetal growth restriction
FNHTR
Febrile non-hemolytic transfusion reaction
FRU
First referral unit
GVHD
Graft versus host disease
HDU
High dependency unit
HELLP
Hemolysis, elevated liver enzymes, low platelets
HTR
Hemolytic transfusion reaction
IBCT
Incorrect blood component transfusion
ICU
Intensive care unit
IUFD
Intrauterine fetal demise
MMR
Maternal mortality ratio
MODS
Multiple organ dysfunction syndrome
MTP
Medical termination of pregnancy
NCPE
Non-cardiogenic pulmonary edema
NGO
Non-government organization
NICE
National institute of clinical excellence
NICU
Neonatal intensive care unit
NRHM
National rural health mission
PC
Packed cells
PCWP
Pulmonary capillary wedge pressure
PE
Pulmonary embolism
PID
Pelvic inflammatory disease
PIH
Pregnancy-induced hypertension
POPPHI
Prevention of postpartum hemorrhage initiative
PPH
Postpartum hemorrhage
PPS
Postphlebitic syndrome
PTP
Post-transfusion purpura
PT
Prothrombin time
RA
Regional anesthesia
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SAB
Subarachnoid block
SHOT
Serious hazards of transfusion
SIRS
Systemic inflammatory response syndrome
TACO
Transfusion-associated circulatory overload
TAS
Transfusion-associated sepsis
TBA
Trained birth assistant
TRALI
Transfusion-related acute lung injury
UH
Unfractionated heparin
VBAC
Vaginal birth after cesarean
VTE
Venous thromboembolism