How to cite this article: Garibaldi-Zapatero J, Than-Gómez MT, Guerrero-Rivera S, Cuevas-García CF. [Maternal morbidity and mortality in a unit of tertiary care without obstetrics]. Rev Med Inst Mex Seguro Soc. 2016;54(2):196-202.
Received: December 8th 2014
Accepted: October 13th 2015
Julio Garibaldi-Zapatero,a M. Teresa Than-Gómez,b Susana Guerrero-Rivera,c Carlos Fredy Cuevas-Garcíad
aDivisión de Calidad de la Atención Médica
bServicio de Admisión Continua
cDivisión de Investigación
Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
Communication with: Julio Garibaldi Zapatero
Telephone: 5627 6900, extensión 20419
Background: Maternal morbidity is a health problem for developing countries, the causes of death among obstetric patients varies according to geographic region and other factors, which include health services. The aim of this study was to identify the causes of maternal mortality and morbidity, as well as factors associated with mortality in patients attending on 2011-2012.
Methods: Clinical data of the patients on admission, severity of illness, presence of comorbidity, complications that occurred during treatment and causes of death in pregnant or postpartum patients were analyzed.
Results: 137 patients were analyzed, 87 (63.5 %) patients were hospitalized, 36 (41.3 %) cases with severe maternal complication (SMC); most patients with SMC were in the postpartum postcesarean. Eleven patients died, five maternal deaths and 6 late deaths.
Conclusions: SMC and death were more frequent in the postpartum period. The indirect causes of death were more frequent.
Keywords: Maternal mortality; Pregnant women; Pregnancy complications
Maternal health is a priority worldwide, it is considered a reliable indicator of quality of care and health service coverage.1 Maternal deaths are preventable deaths, i.e., with the resources available today, it is possible in a timely manner to prevent, detect, and treat women at risk for complications that can lead to death.2,3
The World Health Organization (WHO) defines maternal death as the death of a woman while pregnant, during childbirth, or within 42 days after the end of pregnancy, regardless of its duration and site, from any cause related to or aggravated by pregnancy or its management, but not from accidental or incidental causes.2 According to WHO data, one in every 180 pregnant women is at risk of death.4 The maternal mortality ratio (MMR) depends on geographical factors, development conditions, cultural diversity, and more. The MMR in Mexico is estimated at 50 cases per one hundred thousand live births. In developed countries, one in 3800 women dies, while in Mexico one in every 790 dies.3-5
Because Mexico is one of 75 countries committed to improving maternal health, as part of the WHO Millennium Development Goals, it has implemented several actions, including the Programa de Acción Específico, Arranque Parejo en la Vida (APV), the Programa de Planificación Familiar y Anticoncepción (2007-2012), the agreement of the IMSS Technical Council for the care of women without medical coverage (2006), the Programa Embarazo Saludable, and the Acuerdos para el Fortalecimiento de las Acciones de Salud Pública en los Estados 2007 (AFASPE),3,5-7 in order to reduce MMR.8
The Instituto Mexicano del Seguro Social (IMSS) serves approximately 50% of the country's population, which includes a large proportion of pregnant women who are treated at all levels of health care. The first level is responsible for obstetric monitoring through subsequent visits that identify health problems as pregnancy develops. Most deliveries and cesarean sections are performed on the second level, while patients with high-risk pregnancies are treated on the third level. In recent years programs at all levels of care have intensified in order to prevent maternal morbidity and mortality; efforts have not been in vain; according to recent data, MMR has been reduced to 29 cases per 100,000 live births.6,7
The IMSS organization has highly specialized medical units (unidades médicas de alta especialidad, UMAE) without gynecology departments; such is the case of UMAE Hospital de Especialidades Centro Médico Nacional Siglo XXI (CMN SXXI). Critically ill patients from different levels of care are referred to this unit. The reasons for care appear to be different from other hospitals, which is why it was decided to analyze the reason for visits and causes of morbidity and mortality for obstetric patients treated in the UMAE over a period of two years.
The clinical records were analyzed for all obstetric patients who visited the IMSS UMAE Hospital de Especialidades CMN SXXI from January 2011 to December 2012. Researchers recorded age, gynecological and obstetric history, comorbidity, prenatal care, gestational stage or status, reason for visit or transfer to UMAE, if they required hospitalization, diagnosis, and outcome of hospitalization.
Serious maternal complication (SMC) was considered as a serious complication that occurs during pregnancy, childbirth, and postpartum, threatening the life of the woman or requiring immediate attention in order to avoid death.8,9
Direct obstetric death is maternal death due to obstetric complications of the gravid-puerperal state due to interventions, omissions, incorrect treatment, or a series of events resulting from these, the direct causes including preeclampsia-eclampsia, hemorrhage, obstetric sepsis, miscarriage, prolonged labor, and others.
Indirect obstetric maternal death is death resulting from a preexisting disease or one developed during pregnancy not due to direct obstetric causes but aggravated by the physiological effects of pregnancy; indirect causes include diseases that occur before pregnancy and may worsen during it, or beginning in pregnancy or postpartum.4,9
Late maternal death is the death of a woman from direct or indirect obstetric causes after 42 days but before one year from the end of pregnancy.4,9
Near-miss maternal events are considered: "a woman who nearly died from but survived a complication occurring during pregnancy, childbirth, or the first 42 days of the end of pregnancy". The near-miss maternal mortality event rate is defined as the ratio of near-miss maternal events to maternal deaths; it is held that the higher the index the better.
Descriptive statistics were used with averages, ranges, and proportions according to the type of variable analyzed, and the risks of death were calculated in postpartum women and pregnant patients.
The protocol was approved by the local health research ethics committee 36D1 with the registration number: R-2013-3601-217.
137 patients were treated, median age was 28 years (range 15-45 years), frequency by age group was: 15-20 years: 10 patients; 21-30: 75 patients, 31-39: 49 patients; 40-45 years: 5 patients. 75 were pregnant (55%) and 62 postpartum (45%) (Table I). The most frequent causes of emergency visits were obstetrical, followed by gastrointestinal, neurological, and hematological (Table II). Of the 137 patients treated, 87 (63%) were admitted to one of the medical or surgical specialties; of these, 36 (41.3%) were admitted to the Intensive Care Unit (ICU). The clinical characteristics of the patients admitted to the ICU compared with those not admitted to the ICU are shown in Table III. Of the patients admitted to the ICU, 26 (72.2%) were in the post-cesarean postpartum period.
|Table I Clinical characteristics of living versus deceased obstetric patients|
|Age (mean ± SD)||28.94 ± 6.24||30,36 ± 4.92||0.39|
|Prenatal care*n= 57|
|Yes||41 (32.5%)||5 (45.5%)||0.55|
|Status or condition|
|Physiological postpartum||11 (8.7%)||4 (36.4%)|
|Surgical postpartum||38 (30.2%)||7 (63.6%)|
|Table II Diagnostics of obstetric patients treated in UMAE by specialty|
|Complicated preeclampsia-eclampsia: HELLP,
hepatic subcapsular hematoma, etc.
|Near miscarriage, miscarriage in progress, near premature labor||10|
|Acute calculous cholecystitis||7|
|Unspecified abdominal pain||3|
|Postoperative of exploratory laparotomy/ abdominal sepsis||3|
|Acute abdomen ruptured ectopic pregnancy||2|
|Chronic nonspecific ulcerative colitis||2|
|Acid peptic disorders / gastro-esophageal reflux||2|
|Hypoxic-ischemic, metabolic encephalopathy||2|
|Multiple sclerosis, optic neuritis||2|
|Acute myeloid leukemia||1|
|Glomerulonephritis / nephrotic syndrome||6|
|Chronic kidney disease||4|
|Deep vein thrombosis||3|
|Acute arterial insufficiency||1|
|Pelvic arteriovenous malformation||1|
|Table III Differences of patients admitted to ICU versus not|
|Age (mean ± SD)||30.69 ± 5.9||28.47 ± 6.1|
|Physiological postpartum||6 (16.7%)||9 (8.9%)|
|Post-cesarean postpartum||26 (72.2%)||19 (18.8%)|
|Pregnancy||3 (8.3%)||71 (71.3%)|
|Miscarriage||1 (2.8%)||1 (1%)|
|Primigravid*||10 (62.5%)||49 (69%)|
|≥ 2 pregnancies||6 (37.5%)||22 (31%)|
|*this data was obtained in 87 patients|
Regarding the patients’ origins, 99 (72.3%) were local (Mexico City) and 27 (19.7%) from elsewhere; 28 (20.4%) were referred from primary care, 62 (45.3%) from secondary care, and 47 (34.3%) from tertiary care. Of the 47 who attended tertiary care, 38 (80.8%) were referred to a hospital for gynecology and obstetrics. Of the 36 patients admitted to the ICU, 24 came from second level of care, one from first level, and 11 from third level of care; eight of these patients were from outside the city.
Fifteen patients had a history of disease: hypertension in 2, diabetes mellitus in 2, acromegaly in 2, and asthma, systemic lupus erythematosus, rheumatoid arthritis, epilepsy, obesity, neurocysticercosis, type II multiple endocrine neoplasia, choledochal cyst, and ulcerative chronic colitis in one case each.
The most frequent clinical diagnoses were thrombocytopenic purpura in 9, pancreatitis in 8, hypertensive disease in pregnancy in 7, cerebrovascular disease-associated hypertensive disease in pregnancy in 6, cholecystitis in 6, near miscarriage in 4, abdominal sepsis in 4, fatty liver in pregnancy in 4, and chronic kidney disease in 4.
The most frequent diseases in pregnant patients who were treated were: 1) gastrointestinal with surgical resolution (acute cholecystitis, acute appendicitis, mesenteric thrombosis, ruptured ectopic pregnancy); 2) nephrological diseases (glomerulonephritis, nephrotic syndrome, and chronic renal disease); 3) hematological diseases (pregnancy-associated thrombocytopenia, primary immune thrombocytopenia, and anemia syndrome); 4) neurological diseases (cerebral vascular event (cerebrovascular disease), headache of diverse etiology, and peripheral neuropathies), and 5) obstetric pathologies (near miscarriage and miscarriage in development).
The ICU admission diagnoses were related to obstetrical problems in 19 patients, seven had gastroenterological problems, four with nervous system, three hematological, two peripheral vascular and rheumatological.
In two patients in the second trimester of pregnancy, it was necessary to interrupt the pregnancy to treat the underlying condition, after assessing a high risk of maternal mortality among colleagues. One of the patients had a pelvic trunk arteriovenous malformation with high flow involving the uterus, and was successfully treated with embolization and surgical resection; the other patient had a giant choledochal cyst.
Of the patients admitted to ICU, 19 who met criteria for SMC were discharged to another service upon improvement, and 7 returned to their referral hospital.
Eleven (13%) of hospitalized patients died, ten of those admitted to the ICU and one hospitalized in gastroenterology. The median age of the 11 patients was 29.9 years. Three patients were from outside the city; one was sent from first level, eight from second level, and two from third level care. Of these patients seven (63%) were in the post-cesarean section postpartum period.
Diagnoses of death were: hypertensive disease in pregnancy in two patients, hypertensive disease in pregnancy and CVE in one, decidual endometritis, pancreatitis, abdominal sepsis, giant choledochal cyst, fatty liver in pregnancy, hemorrhagic stroke, lymphoma, and leukemia, in one case each.
Five of the deaths were maternal deaths (direct and indirect), and six were late deaths.
In the patient with the giant choledochal cyst, it was decided to terminate the pregnancy for surgical resection of the cyst, but she unfortunately died (Table IV).
|Table IV Underlying cause and cause of death in obstetric patients treated in UMAE|
|No.||Age||Cause of death||Underlying cause||Pregnancy resolution||Death|
|1||25||DIC, hypovolemic shock||Preeclampsia- Hellp syndrome, disseminated intravascular coagulation, postoperative of exploratory laparotomy, dissecting hematoma||C||DO|
|2||36||Cerebral edema||Subarachnoid hemorrhage Fisher IV, gestational hypertension||C||IO|
|3||30||Hypovolemic shock||Complicated pre-eclampsia, disseminated intravascular coagulation||C||DO|
|4||35||Multiple organ failure||Septic shock, hypovolemic shock, postoperative of exploratory laparotomy, decidual endometritis.||A||DO|
|5||28||Subarachnoid hemorrhage Fisher IV||Cerebral edema, anterior cerebral arterial aneurysm||PB||IO|
|6||31||Septic shock||Intra-abdominal sepsis, exploratory laparotomy, hepatico-jejunal anastomosis, postoperative of giant choledochal cyst||C||L|
|7||26||Hypovolemic shock||Von Willebrand disease||C||L|
|8||24||Consumptive coagulopathy||Severe acute pancreatitis, nosocomial pneumonia, cholecystectomy, obesity||PB||L|
|9||37||Massive pulmonary thromboembolism||Follicular B-cell lymphoma||PB||L|
|10||26||Cerebral hemorrhage||Acute myeloid leukemia M3||PB||L|
|11||36||Acute liver failure||Acute kidney injury, non-alcoholic steatohepatitis||PB||L|
|C = caesarian section;A = abortion;PB = physiological birth;DO = directly obstetrical;
IO = indirectly obstetrical;L = late
Maternal morbidity and mortality is a health problem that occurs most frequently in developing countries.3-5 IMSS is responsible for the care of a large part of the Mexican population, including pregnant patients. The UMAE Hospital de Especialidades serves acute medical and surgical problems that are difficult to treat at other levels of care; this UMAE has no department of gynecology and obstetrics, which makes the management of pregnant patients more challenging.
In Mexico, as in other countries, one of the causes of maternal death relates to the delay in medical care,10 due among other things to the lack of decision to seek help at the moment of complication; for this reason it is important to counsel patients about hospitals they can go to in case of complications.
Among the comprehensive strategies to accelerate the reduction of maternal mortality in Mexico, there is the one promoted by Averting Maternal Death and Disability Program AMDD, (Columbia University, NY),11 which is aimed at resolving emergency obstetric care, aiming to educate the population to identify warning signs in pregnant patients with complications to refer them to first and second level health services on time. Meeting this objective requires a network of health services with the material and human resources required 24 hours 365 days a year, in order to provide operative emergency care in both first and the second level medical care.
This behavior has been adopted in the UMAE, with a communication network that alerts the different medical and surgical services for the multidisciplinary and timely care these patients need. In these cases the continuous admission service evaluates all patients who come to the UMAE and refers them to the appropriate level of medical care, according to the in-hospital diagnosis.
The main reasons for visits were obstetric conditions, followed by non-obstetric, including gastrointestinal disorders with surgical resolution, and neurological, renal, and hematological diseases. Unlike other studies,12 cardiological diseases were not observed, probably because patients with these disorders come or are referred to UMAE Hospital de Cardiología.
Of the group that required hospitalization, 41% were admitted to the ICU; most of the patients who were in the post-cesarean section postpartum period, unlike the patients admitted to the floor, most of whom were pregnant.
For causes of maternal death, three were direct and two indirect, the first ones related to preeclampsia and DIC. Unlike other authors,10-15 late obstetric death from indirect causes was the most frequent, found in 6 patients; two patients had blood diseases, one case of Von Willebrand disease, and three with gastrointestinal problems. Fajardo et al.12 reported 54.91% direct deaths, 42.1% due to obstetric hemorrhage; 35.7% hypertensive disease in pregnancy, and 11.6% puerperal infection, among others; the indirect causes included in first place atypical pneumonia coinciding with the H1N1 influenza outbreak, in second place malignancies, followed by abdominal sepsis secondary to surgical gastrointestinal problems, CVE, and ischemic heart disease. In the study by Ruiz Rosas,16 direct causes were the most frequent, and the indirect causes included cardiovascular system diseases and neoplasms in the first places.
The highest frequency of indirect deaths in our population can be explained by referral bias, since patients are sent for care by medical and surgical specialties found in the UMAE, which are different from the pathologies treated in OB-GYN units.7,16
The results observed in the study indicate that patients with greater risk of complications and maternal mortality are found in the late postpartum period.17 SMC risk is higher in patients with cesarean section postpartum compared with childbirth postpartum and pregnancy, however the risk was not significantly higher between cesarean section postpartum and childbirth postpartum. Caesareans are associated with increased risk of serious complications such as hemorrhage, infection, cervical laceration, or cervical vascular injury and thromboembolism.18,19 National efforts have been made to reduce the number of caesarean sections and promote vaginal delivery.
The results observed in the study indicate that patients with greater risk of complications and maternal mortality are found in the late postpartum period.16 SMC occurred more frequently in patients with surgical postpartum compared with physiological postpartum and pregnancy. The postpartum period is, therefore, a period of high risk for serious complications, regardless of the route of birth. However, some authors agree that the cesarean section postpartum period, especially emergency caesarean section, is associated with serious complications such as bleeding, infection, cervical laceration, or cervical vascular injury and thromboembolism.17,18
A large proportion of patients with serious complications survived; the diagnoses of these patients were mostly directly obstetrical. Multidisciplinary ICU management was fundamental to the control of complications.
Among the strategies to reduce maternal death should be closer monitoring of patients during physiological and surgical postpartum periods, both early and late and, where possible, reducing the number of emergency caesarean sections and promoting vaginal delivery. However, the importance of prenatal care for complications that can be treated or controlled is well known and established in NOM-007-SSA2-1993.19
The present study observed that some patients presented with serious non-obstetrical diseases during pregnancy that are unpredictable, but that can be detected in a timely manner with good prenatal care, as in the case of acute cholecystitis, severe acute pancreatitis, some kidney diseases, leukemias, and lymphomas.
20% of patients were known to have diseases before pregnancy requiring special monitoring because of the high risk of complications during pregnancy. In these patients it is paramount to use family planning methods.20,21
The UMAE the working group was established in 2011 to monitor maternal morbidity and mortality, with the participation of critical care areas as part of the rapid response team, and the multidisciplinary management of obstetric patients was intensified in order to increase monitoring and quality of care, as well as improved specific resource and intervention management.22
CMN SXXI Hospital de Especialidades as part of IMSS joins the international and national commitment to implementing strategies to improve the professional care of maternal patients.23
The main causes of mortality observed in this study were indirect and late maternal causes. Patients with increased risk of death were those in the postpartum period, especially after caesarean section; close monitoring of patients is required at this stage to identify and treat any complications in a timely manner. Knowledge of pathology in obstetric patients treated in the UMAE will allow the implementation of strategies to improve health care for this group of patients.
Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.