Evaluation of a strict protocol approach in managing women with severe disease due to abortion.
OBJECTIVE
To evaluate whether the introduction of a strict protocol approach based on the systemic evaluation of critically ill pregnant women with complications of abortion affected outcome.


METHODS
Indigent South Africans managed in the regional and tertiary hospitals of the Pretoria Academic Complex.


METHODS
Since 1997 a standard definition of severe acute maternal morbidity (SAMM) has been used in the Pretoria Academic Complex. All cases of SAMM and maternal deaths were entered on the Maternal Morbidity and Mortality Audit System programme. A comparison of outcome of severely ill women who had complications of abortion was made between 1997-1998 (original protocol) and 2002-2004 (strict protocol).


METHODS
The mortality index and prevalence of organ system failure or dysfunction.


RESULTS
In 1997-1998 there were 43 women with SAMM who survived and a further 10 maternal deaths due to complications of abortion, compared with 107 women with SAMM and 7 maternal deaths during 2002-2004. The mortality index declined from 18.9% in 1997-1998 to 6.1% in 2002-2004 (p = 0.02, odds ratio 0.28, 95% confidence limits 0.10 - 0.79). Significantly more women had hypovolaemic shock in 2002-2004 compared with 1997-1998 (54.4% v. 35.8%, p = 0.04), but fewer women had immune system failure including septic shock (18.4% v. 47.2%, p = 0.0002) and metabolic dysfunction (0 v. 5.7%, p = 0.03) and there was a trend to less renal failure (10.5% v. 22.6%, p = 0.06) and cardiac failure (4.4% v. 13.2%, p = 0.08).


CONCLUSIONS
The strict protocol approach based on systemic evaluation in managing critically ill pregnant women with complications of abortion, coupled with an intensive, regular feedback mechanism, has been associated with a reduction in the mortality index.
Pattinson
R C
RC
MRC Maternal and Infant Health Care Strategies Research Unit and Department of Obstetrics and Gynaecology, University of Pretoria, South Africa.
Snyman
L C
LC
Macdonald
A P
AP
D000028:Abortion, Induced / Q000009:adverse effects*; D000328:Adult; D003422:Critical Care / Q000379:methods*; D005260:Female; D006801:Humans; D008428:Maternal Mortality; D008875:Middle Aged; D011247:Pregnancy; D011248:Pregnancy Complications / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D011787:Quality of Health Care; D012720:Severity of Illness Index; D013019:South Africa / Q000453:epidemiology; D016019:Survival Analysis