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Background
A maternal near miss refers to a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of pregnancy.1 Approximately 20 million acute complications of pregnancy occur globally every year.2 Improvement in healthcare means that increasing numbers of women are surviving acute morbidity events but the long-term repercussions of these events have not been evaluated fully. There is some evidence suggesting that maternal ill health continues beyond the immediate post-partum period and might affect women‟s lives. A study in Burkino Faso has shown that women with severe obstetric complications, and their babies were significantly more likely to die after discharge compared with women with an uncomplicated delivery.3 Women with severe obstetric complications are also more likely to experience depression, anxiety and suicidal thoughts.
Other investigators have evaluated the repercussions of severe biological or traumatic events and have reported that survivors are at an increased risk of death in the five years after the event.4 After release from hospital, these patients continue to develop both organic and emotional problems, including cardiac, respiratory and neurological complications.5One of the principle advantages of studying near-misses, is the possibility of hearing the experience of women directly. These women are believed to be able to adequately report the obstacles and delays they face to assure their continued survivial.6 Pregnancy can be looked at as a “stress test.” During this period certain organ systems become vulnerable to dysfunction or failure. It is important to find the correct balance between maternal well-being and optimal timing of delivery of the neonate. Prolonging a pregnancy as a result of excessive concern for the neonate can be detrimental to maternal health.
Although a maternal near miss case can only be identified retrospectively, it is clinically useful to prospectively identify women with potentially life-threatening conditions. A woman who develops a life-threatening condition is either a maternal near miss or a maternal death. According to the Saving Mothers Report, 26.7% of maternal deaths in South Africa during 2011-2013 were probably avoidable and a further 32.8% were considered possibly avoidable.7 Obstetric emergencies may occur in women with known risk factors however a significant proportion of serious complications in pregnancy occur in women with no identifiable risk factors.
Several factors may influence a woman‟s ability to access appropriate obstetric care. Evaluating circumstances around near-miss cases have the advantage over maternal death cases because near-miss patients are able to provide direct information after an event. Say et al have described the spectrum of morbidity from an uncomplicated pregnancy to further progression to maternal death.8 (Figure 1) There were 41 687 births in the Pretoria Academic Complex between January 2008- December 2009.9The maternal near miss incidence ratio (MNM IR) (number of maternal near miss cases per 1000 live births [MNM IR=MNM/LB]) for this period was 8.99 per 1000 births. The most common causes of severe morbidity during this period was, obstetric haemorrhage, hypertension, pre-existing medical and surgical conditions and complications associated with miscarriage. There were more women with life-threatening conditions associated with pre-existing medical and surgical conditions and complications of hypertension in 2008-2009 than during the periods 1997-1998 and 2002-2004.
In the WHO Global survey, (WHOMCS 2012) postpartum haemorrhage and preeclampsia/ eclampsia were the most frequent obstetric complications found among women with severe maternal outcomes (26.7% and 25.9% respectively).10 Intensive care-unit admission, hysterectomy, blood transfusion, cardiac or renal complications and eclampsia were the most important indicators of severe maternal morbidity according to the WHO global survey on maternal and perinatal health.
Motivation for the study
It is unknown whether continuing a pregnancy in a patient with severe organ dysfunction does long-term harm to maternal health. The extent of this “harm” is also unknown. We are also uncertain whether this organ dysfunction is a continuum and progressively becomes worse or whether there is a “critical level” of organ dysfunction which in the long-term leads to organ failure. This study aims to describe the long term outcome of pregnant women with life threatening conditions and to start addressing the question whether pregnant women with potentially life threatening conditions should be delivered earlier to protect them from long term maternal ill-health.
Research Problem
The primary aim of this study was to investigate the long-term organ system function in a group of women who have suffered severe morbidity in pregnancy and further compare this group to a control group of low-risk women who have had a normal pregnancy outcome. We also investigated whether the insult associated with severe morbidity in pregnancy predisposed this group of vulnerable women to further long-term organ dysfunction.
CHAPTER 1 – Maternal near miss and maternal death in the Pretoria Academic Complex, South Africa: A population-based study
1.1 INTRODUCTION
1.2 METHODS
1.3 RESULTS
1.4 DISCUSSION
1.5 RECOMMENDATIONS
1.6 CONCLUSION
1.7 REFERENCES
CHAPTER 2 – Barriers to obstetric care among maternal near-misses
2.1 INTRODUCTION
2.2 OBJECTIVES
2.3 METHODS
2.4 RESULTS
2.5 DISCUSSION
2.6 STRENGTHS AND LIMITATIONS
2.7 CONCLUSION
2.8 REFERENCES
CHAPTER 3 – Cerebral white matter lesions after pre-eclampsia
3.1 INTRODUCTION
3.2 METHODS
3.3 RESULTS
3.4 DISCUSSION
3.5 CONCLUSION
3.6 REFERENCES
CHAPTER 4 – Cardiac diastolic function after recovery from pre-eclampsia
4.1 INTRODUCTION
4.2 METHODS
4.3 RESULTS
4.4 DISCUSSION
4.5 CONCLUSION
4.6 REFERENCES
CHAPTER 5 – The effect of pre-eclampsia on retinal microvascular caliber at delivery and post-partum
5.1 INTRODUCTION
5.2 METHODS
5.3 RESULTS
5.4 DISCUSSION
5.5 CONCLUSION
5.6 FUNDING
5.7 REFERENCES
CHAPTER 6 – Quality of life one year after severe acute maternal morbidity
6.1 INTRODUCTION
6.2 METHODS
6.3 RESULTS
6.4 DISCUSSION
6.5 CONCLUSION
6.6 REFERENCES
CONCLUSION AND RECOMMENDATIONS
REFERENCES
