Evaluation of a strict protocol approach in managing women with severe disease due to hypertension in pregnancy: A before and after study
Department of Obstetrics and Gynaecology, Kalafong Hospital, Private Bag X396, Pretoria 0001, South Africa; MRC Maternal and Infant Health Care Strategies Research Unit, Obstetrics and Gynaecology Department, University of Pretoria, South Africa
Background: To evaluate whether the introduction of a strict protocol based on the systemic evaluation of critically ill pregnant women with complications of hypertension affected the outcome of those women. Method: Study group: Indigent South African women managed in the tertiary hospitals of the Pretoria Academic Complex. Since 1997 a standard definition of women with severe acute maternal morbidity (SAMM), also referred to as a Nearmiss, has been used in the Pretoria Academic Complex. All cases of SAMM and maternal deaths (MD) were entered on the Maternal Morbidity and Mortality Audit System programme (MaMMAS). A comparison of outcome of severely ill women who had complications of hypertension in pregnancy was performed between 1997-1998 (original protocol) and 2002-2003 (strict protocol). Data include women referred from outside the Pretoria Academic Complex area to the tertiary hospitals. Results: Between 1997-1998 there were 79 women with SAMM and 18 maternal deaths due to complications of hypertension, compared with 91 women with SAMM and 13 maternal deaths in 2002-2003. The mortality index (MI) declined from 18.6% to 12.5% (OR 0.62, 95% CI 0.27-1.45). Statistically significant fewer women had renal failure (RR 0.37, 95% CI 0.21 - 0.66) and cerebral complications (RR 0.52, 95%CI 0.34 - 0.81) during the second period, and liver dysfunction (RR 0.27 95%CI 0.06 - 1.25) tended to be lower. However, there tended to be an increase in the number of women, who had immune system failure (RR 4.2 95%CI 0.93 - 18.94) and respiratory failure (RR 1.42 95%CI 0.88 - 2.29) although it did not reach significance. Cardiac failure remained constant (RR 0.84 95%CI 0.54 - 1.30). Conclusion: The strict protocol approach based on the systemic evaluation of severely ill pregnant women with complications of hypertension and an intensive, regular feedback mechanism has been associated with a reduction in the number of patients with renal failure and cerebral compromise. © 2005 Lombaard et al; licensee BioMed Central Ltd.
dihydralazine; haloperidol; labetalol; methyldopa; nifedipine; Ringer lactate solution; adolescent; adult; article; breathing rate; cause of death; clinical examination; clinical feature; clinical protocol; comparative study; controlled study; critical illness; deep vein thrombosis; disease severity; feedback system; female; fetus monitoring; fluid therapy; Glasgow coma scale; heart failure; heart size; heart sound; hospital; human; immunopathology; kidney failure; liver dysfunction; major clinical study; maternal hypertension; maternal morbidity; maternal mortality; Negro; neurologic disease; ophthalmoscopy; oxygen therapy; patient referral; reflex; respiratory failure; socioeconomics; South Africa; statistical significance; treatment outcome