Maternal near miss management and maternal mortality prevention

doi:10.3877/cma.j.issn.1673-5250.2018.01.002

Maternal mortality ratio (MMR) is one of the important indicators for assessing the health status of pregnant women and socioeconomic development. With the development of economy and health status of pregnant women, MMR has continuously decreased especially in developed countries where maternal death is rare. Only using the available information from maternal death or MMR can no longer comprehensively evaluate the quality of maternal health care and the development of women′s health care. Additionally, it is difficult to provide adequate and effective information to improve maternal health policies because of a small number of maternal deaths. Maternal near miss management as an early indicator to describe the dynamic process of maternal death, has great significance for strengthening the dynamic management of maternal deaths and reducing MMR. In order to strengthen the emergency management system of maternal near miss, we review the global management and rescue status of maternal near miss and sum up the experience, to effectively improve the efficiency and quality of maternal rescue, and to reduce the MMR.

Key words: Maternal mortality, Maternal near miss morbidity, Management, Prevention, Maternal near miss

图1 孕产妇分类

表1 世界卫生组织制定的危重孕产妇诊断标准

危重孕产妇诊断标准		危重孕产妇诊断标准
临床标准		实验室标准
?	急性发绀	?	血清肌酐浓度≥300 μmol/L(3.5 mg/dL)
?	喘息	?	血清胆红素浓度>10.0 μmol/L(6.0 mg/dL)
?	呼吸频率>40次/min，或<6次/min	?	全血液pH值<7.1
?	休克	?	全血液乳酸浓度>5 mmol/L
?	采取补液措施或使用利尿剂无效的少尿	?	急性血小板计数降低<50×10⁹/L(50 000/mm³)
?	凝血功能障碍	?	意识丧失伴尿糖或者尿酮呈阳性
?	意识丧失持续时间≥12 h	基于救治措施的标准
?	意识丧失伴脉搏或(和)心跳停止	?	持续使用血管活性物质
?	脑卒中	?	感染或者产科出血导致的子宫切除
?	无法控制的痉挛或全身瘫痪	?	静脉输注红细胞≥5 U
?	子痫前期伴黄疸症状	?	与麻醉无关的气管插管及通气时间≥60 min
实验室标准		?	因急性肾功能衰竭而采取血液透析治疗
?	动脉血氧饱和度<90%的持续时间>60 min	?	采取心肺复苏治疗
?	动脉血氧分压与吸入氧气分数的比值<26.7 kPa(200 mmHg)	?	?

表1 世界卫生组织制定的危重孕产妇诊断标准

危重孕产妇诊断标准		危重孕产妇诊断标准
临床标准		实验室标准
?	急性发绀	?	血清肌酐浓度≥300 μmol/L(3.5 mg/dL)
?	喘息	?	血清胆红素浓度>10.0 μmol/L(6.0 mg/dL)
?	呼吸频率>40次/min，或<6次/min	?	全血液pH值<7.1
?	休克	?	全血液乳酸浓度>5 mmol/L
?	采取补液措施或使用利尿剂无效的少尿	?	急性血小板计数降低<50×10⁹/L(50 000/mm³)
?	凝血功能障碍	?	意识丧失伴尿糖或者尿酮呈阳性
?	意识丧失持续时间≥12 h	基于救治措施的标准
?	意识丧失伴脉搏或(和)心跳停止	?	持续使用血管活性物质
?	脑卒中	?	感染或者产科出血导致的子宫切除
?	无法控制的痉挛或全身瘫痪	?	静脉输注红细胞≥5 U
?	子痫前期伴黄疸症状	?	与麻醉无关的气管插管及通气时间≥60 min
实验室标准		?	因急性肾功能衰竭而采取血液透析治疗
?	动脉血氧饱和度<90%的持续时间>60 min	?	采取心肺复苏治疗
?	动脉血氧分压与吸入氧气分数的比值<26.7 kPa(200 mmHg)	?	?

表2 早期识别潜在危重孕产妇的临床指标

临床指标		临床指标
出血性疾病		其他系统疾病
?	胎盘早剥	?	抽搐
?	胎盘植入	?	脓毒血症
?	异位妊娠	?	休克
?	产后出血	?	血小板计数<100×10⁹/L
?	子宫破裂	?	甲状腺危象
妊娠期高血压疾病		以严重的处理措施为识别的指标
?	重度子痫前期	?	输血
?	子痫	?	中心静脉置管
?	严重原发性或妊娠期高血压	?	子宫切除术
?	高血压性脑病	?	入住ICU
?	HELLP综合征	?	住院时间长(产后>7 d)
其他系统疾病		?	非麻醉的气管插管
?	子宫内膜炎	?	重返手术室
?	肺水肿	?	手术干预
?	呼吸衰竭	?	?

表2 早期识别潜在危重孕产妇的临床指标

临床指标		临床指标
出血性疾病		其他系统疾病
?	胎盘早剥	?	抽搐
?	胎盘植入	?	脓毒血症
?	异位妊娠	?	休克
?	产后出血	?	血小板计数<100×10⁹/L
?	子宫破裂	?	甲状腺危象
妊娠期高血压疾病		以严重的处理措施为识别的指标
?	重度子痫前期	?	输血
?	子痫	?	中心静脉置管
?	严重原发性或妊娠期高血压	?	子宫切除术
?	高血压性脑病	?	入住ICU
?	HELLP综合征	?	住院时间长(产后>7 d)
其他系统疾病		?	非麻醉的气管插管
?	子宫内膜炎	?	重返手术室
?	肺水肿	?	手术干预
?	呼吸衰竭	?	?

表3 危重孕产妇发生率与危重孕产妇高危因素及其所占比例

年份(年)/作者	调查时间(年)/国家/地区/	发生率			危重孕产妇高危因素及其所占比例
年份(年)/作者	调查时间(年)/国家/地区/	危重孕产妇发生率(%)	MMR(/10⁵)	危重孕产妇例数与孕产妇死亡例数比值	危重孕产妇高危因素及其所占比例
2010/Allen等^[27]	2005—2009/加拿大/所有地区	0.438	6.1	71.8∶1	－
2011/Amaral等^[28]	2005/巴西/Campinas	2.11	－	23.7∶1	妊娠期高血压疾病并发症(57.8%)、产后出血(17.9%)
2011/Jayaratnam等^[29]	2009—2010/澳大利亚/ Cairns Base Hospital	0.6	－	－	产科原因(64%)，包括产后出血(40%)、子痫前期(14%)；非产科原因(36%)，包括肺炎(18%)、非子痫性抽搐(18%)
2013/Ghazal-Aswad等^[30]	2010—2016/沙特阿拉伯/ Abu Dhabi Emirate	0.75	－	－	妊娠期高血压疾病(59.5%)、败血症(39.6%)
2013/Ps等^[31]	2011—2012/印度/Udupi	1.78	313	5.6∶1	产科出血(44.2%)、妊娠期高血压疾病(23.6%)、败血症(16.3%)
2013/中华人民共和国国家卫生计生委^[32]	2012/中国/全部地区	18.5	24.5	755.1∶1	－
2015/王鑫等^[33]	2012/中国/重庆市、广西壮族自治区与陕西省	0.304	9.92	重庆市：0∶1 广西壮族自治区：20.5∶1 陕西省：51.1∶1	产科出血(54.90%)、妊娠期高血压疾病(29.86%)、贫血(48.99%)
2016/刘智昱等^[34]	2012—2013/中国/湖南省	0.308	－	－	产科出血(36. 2%)、妊娠期高血压疾病(29.8%)、贫血(21.3%)、感染(14.9%)
2017/吕霄等^[35]	2014—2015/中国/广东省	0.24	6.96	34.5∶1	贫血(49.61%)、产科出血(15.37%)、妊娠期糖尿病(6.52%)
2017/张达明等^[36]	2014/中国/山西省	0.398	11.45	34.8∶1	贫血(199.82%)、产科出血(76.58%)、妊娠期糖尿病(56.86%)、妊娠期高血压疾病(56.25%)

表3 危重孕产妇发生率与危重孕产妇高危因素及其所占比例

年份(年)/作者	调查时间(年)/国家/地区/	发生率			危重孕产妇高危因素及其所占比例
年份(年)/作者	调查时间(年)/国家/地区/	危重孕产妇发生率(%)	MMR(/10⁵)	危重孕产妇例数与孕产妇死亡例数比值	危重孕产妇高危因素及其所占比例
2010/Allen等^[27]	2005—2009/加拿大/所有地区	0.438	6.1	71.8∶1	－
2011/Amaral等^[28]	2005/巴西/Campinas	2.11	－	23.7∶1	妊娠期高血压疾病并发症(57.8%)、产后出血(17.9%)
2011/Jayaratnam等^[29]	2009—2010/澳大利亚/ Cairns Base Hospital	0.6	－	－	产科原因(64%)，包括产后出血(40%)、子痫前期(14%)；非产科原因(36%)，包括肺炎(18%)、非子痫性抽搐(18%)
2013/Ghazal-Aswad等^[30]	2010—2016/沙特阿拉伯/ Abu Dhabi Emirate	0.75	－	－	妊娠期高血压疾病(59.5%)、败血症(39.6%)
2013/Ps等^[31]	2011—2012/印度/Udupi	1.78	313	5.6∶1	产科出血(44.2%)、妊娠期高血压疾病(23.6%)、败血症(16.3%)
2013/中华人民共和国国家卫生计生委^[32]	2012/中国/全部地区	18.5	24.5	755.1∶1	－
2015/王鑫等^[33]	2012/中国/重庆市、广西壮族自治区与陕西省	0.304	9.92	重庆市：0∶1 广西壮族自治区：20.5∶1 陕西省：51.1∶1	产科出血(54.90%)、妊娠期高血压疾病(29.86%)、贫血(48.99%)
2016/刘智昱等^[34]	2012—2013/中国/湖南省	0.308	－	－	产科出血(36. 2%)、妊娠期高血压疾病(29.8%)、贫血(21.3%)、感染(14.9%)
2017/吕霄等^[35]	2014—2015/中国/广东省	0.24	6.96	34.5∶1	贫血(49.61%)、产科出血(15.37%)、妊娠期糖尿病(6.52%)
2017/张达明等^[36]	2014/中国/山西省	0.398	11.45	34.8∶1	贫血(199.82%)、产科出血(76.58%)、妊娠期糖尿病(56.86%)、妊娠期高血压疾病(56.25%)

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