Chinese Medical E-ournals Database
Adv Search
中华妇幼临床医学杂志(电子版)

Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition) ›› 2018, Vol. 14 ›› Issue (01): 8 -17. doi: 10.3877/cma.j.issn.1673-5250.2018.01.002

Special Issue: ；

Editorial

Maternal near miss management and maternal mortality prevention

Danni Liu1, Xiaodong Wang1,†(), Zhiyi Zhou1, Guiqiong Huang1, Na Liu1, Juan Liang2,†()   

  1. 1. Department of Gynecology and Obstetrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University
    2. National Center for Birth Defects Monitoring of China, Chengdu 610041, Sichuan Province, China
  • Received:2017-11-20 Revised:2018-01-11 Published:2018-02-01
  • Corresponding author: Xiaodong Wang, Juan Liang
  • About author:
    Corresponding authors: Wang Xiaodong, Email:
    Liang Juan, Email:
HTML ( ) PDF ( )

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
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
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%)
[1]
董子畅. 2016年中国孕产妇死亡率为19.9/10万[N/OL]. 新华网，(2017-01-21) [2017-09-30].

URL    
[2]
WHO Media Centre. Maternal mortality[EB/OL]. (2016-11) [2017-09-30].

URL    
[3]
王坤朔. 《"健康中国2030"规划纲要》发布附全文[N/OL]. 新华网，(2016-10-25) [2017-09-30].

URL    
[4]
陈淑芳，张晨，陈焱，等. 基于"二胎"再育趋势的产科安全影响因素分析及对策探讨[J]. 上海交通大学学报(医学版), 2016, 36(5):742-746.
[5]
孟茜，林鹏. 二胎政策开放与未开放高危妊娠妇女分布人群差异性调查[J]. 中国妇幼保健，2016, 31(20):4266-4268.
[6]
Balasch J, Gratacós E. Delayed childbearing: effects on fertility and the outcome of pregnancy[J]. Curr Opin Obstet Gynecol, 2012, 24(3):187-193.
[7]
Khalil A, Syngelaki A, Maiz N, et al. Maternal age and adverse pregnancy outcome: a cohort study[J]. Ultrasound Obstet Gynecol, 2013, 42(6):634-643.
[8]
Milosevic′, J, Lilic′, V, Tasic′, M, et al. Placental complications after a previous cesarean section[J]. Med Pregl, 2009, 62(5-6):212-216.
[9]
Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta[J]. Am J Obstet Gynecol, 1997, 177(1):210-214.
[10]
Chattopadhyay SK, Kharif H, Sherbeeni MM. Placenta praevia and accreta after previous caesarean section[J]. Eur J Obstet Gynecol Reprod Biol, 1993, 52(3):151-156.
[11]
Global Health Observatory (GHO) Data. Maternal and reproductive health[EB/OL]. (2016) [2017-09-30].

URL    
[12]
World Health Organization. Maternal mortality in 2000: estimates developed by WHO, UNICEF and UNFPA[M]. Geneva: World Health Organization, 2004:1.
[13]
Campbell OM, Graham WJ, Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works[J]. Lancet, 2006, 368(9543):1284-1299.
[14]
吴久玲，罗晓敏. 孕产妇危重症评审方法干预效果研究[J]. 中国妇幼卫生杂志，2013, 4(5):4-6.
[15]
Prual A, Bouvier-Colle MH, de Bernis L, et al. Severe maternal morbidity from direct obstetric causes in West Africa: incidence and case fatality rates[J]. Bull World Health Organ, 2000, 78(5):593-602.
[16]
Okong P, Byamugisha J, Mirembe F, et al. Audit of severe maternal morbidity in Uganda：implications for quality of obstetric care[J]. Acta Obstet Gynecol Scand, 2006, 85(7):797-804.
[17]
de Bernis L, Dumont A, Bouillin D, et al. Maternal morbidity and mortality in two different populations of Senegal: a prospective study (MOMA survey)[J]. BJOG, 2000, 107(1):68-74.
[18]
Mantel GD, Buchmann E, Rees H, et al. Severe acute maternal morbidity: a pilot study of a definition for a near-miss[J]. Br J Obstet Gynaecol, 1998, 105(9):985-990.
[19]
Vandecruys HI, Pattinson RC, Macdonald AP, et al. Severe acute maternal morbidity and mortality in the Pretoria Academic Complex: changing patterns over 4 years[J]. Eur J Obstet Gynecol Reprod Biol, 2002, 102(1):6-10.
[20]
Mayi-Tsonga S, Meyé JF, Tagne A, et al. Audit of the severe obstetrical morbidity (near miss) in Gabon[J]. Sante, 2007, 17(2):111-115.
[21]
Say L, Souza JP, Pattinson RC, et al. Maternal near miss--towards a standard tool for monitoring quality of maternal health care[J]. Best Pract Res Clin Obstet Gynaecol, 2009, 23(3):287-296.
[22]
Pattinson R, Say L, Souza JP, et al. WHO maternal death and near-miss classifications[J]. Bull World Health Organ, 2009, 87(10):734.
[23]
杜培丽，陈敦金. 产科重症监护病房在重症孕产妇救治中的作用[J/CD]. 中华产科急救电子杂志，2015, 4(2):65-67.
[24]
von Dadelszen P, Payne B, Li J, et al. Prediction of adverse maternal outcomes in pre-eclampsia: development and validation of the full PIERS model[J]. Lancet, 2011, 377(9761):219-227.
[25]
Ronsmans C. Severe acute maternal morbidity in low-income countries[J]. Best Pract Res Clin Obstet Gynaecol, 2009, 23(3):305-316.
[26]
van Roosmalen J, Zwart J. Severe acute maternal morbidity in high-income countries[J]. Best Pract Res Clin Obstet Gynaecol, 2009, 23(3):297-304.
[27]
Allen VM, Campbell M, Carson G, et al. Maternal mortality and severe maternal morbidity surveillance in Canada[J]. J Obstet Gynaecol Can, 2010, 32(12):1140-1146.
[28]
Amaral E, Souza JP, Surita F, et al. A population-based surveillance study on severe acute maternal morbidity (near-miss) and adverse perinatal outcomes in Campinas, Brazil: the Vigimoma Project[J]. BMC Pregnancy Childbirth, 2011, 11:9.
[29]
Jayaratnam S, De Costa C, Howat P. Developing an assessment tool for maternal morbidity ' near-miss '：a prospective study in a large Australian regional hospital[J]. Aust N Z J Obstet Gynaecol, 2011, 51(5):421-425.
[30]
Ghazal-Aswad S, Badrinath P, Sidky I, et al. Severe acute maternal morbidity in a high-income developing multiethnic country[J]. Matern Child Health J, 2013, 17(3):399-404.
[31]
Ps R, Verma S, Rai L, et al. " Near miss" obstetric events and maternal deaths in a tertiary care hospital: an audit[J]. J Pregnancy, 2013, 2013:393758.
[32]
中华人民共和国国家卫生计生委. 2013中国卫生统计年鉴[M/OL]. 北京：中华人民共和国国家卫生和计划生育委员，(2014-04-26) [2017-09-30].

URL    
[33]
王鑫，牟祎，刘铮，等. 2012年重庆市、广西壮族自治区和陕西省严重孕产结局发生状况分析[J]. 中国妇幼保健，2015, 30(3):343-346.
[34]
刘智昱，王爱华，孔繁. 湖南省危重孕产妇发生率及影响因素[J]. 实用预防医学，2016, 23(7):791-793.
[35]
吕霄，夏建红，王雄虎. 等.广东省2014—2015年危重孕产妇监测结果分析[J]. 中国妇幼卫生杂志，2017, 8(1):4-7.
[36]
张达明，王苓，白云. 2014年山西省危重孕产妇医院监测结果分析[J]. 中国药物与临床，2017, 17(2):202-203.
[37]
Hodkinson P, Argent A, Wallis L, et al. Pathways to care for critically ill or injured children: a cohort study from first presentation to healthcare services through to admission to intensive care or death[J]. PLoS One, 2016, 11(1):e0145473.
[38]
Fuchs KM, Miller RS, Berkowitz RL. Optimizing outcomes through protocols, multidisciplinary drills, and simulation[J]. Semin Perinatol, 2009, 33(2):104-108.
[39]
World Health Organization, Department of Reproductive Health and Research. Evaluating the quality of care for severe pregnancy complications: the WHO near-miss approach for maternal health[M]．Geneva: World Health Organization, 2011: 8.
[40]
Singh S, McGlennan A, England A, et al. A validation study of the CEMACH recommended modified early obstetric warning system (MEOWS)[J]. Anaesthesia, 2012, 67(1):12-18.
[41]
American College of Obstetricians and Gynecologists Committee on Patient Safety and Quality Improvement. Committee opinion No. 590: preparing for clinical emergencies in obstetrics and gynecology[J]. Obstet Gynecol, 2014, 123(3):722-725.
[42]
Mahlmeister LR. Best practices in perinatal care: the role of rapid response teams in perinatal units[J]. J Perinat Neonatal Nurs, 2006, 20(4):287-289.
[43]
李淑娟，邹桂珍，袁会文，等. 产科联合ICU救治危重孕产妇20例临床分析[J]. 实用医院临床杂志，2013, 10(2):143-144.
[44]
Cecatti JG, Souza JP, Parpinelli MA, et al. Research on severe maternal morbidities and near-misses in Brazil: what we have learned[J]. Reprod Health Matters, 2007, 15(30):125-133.
[45]
Geller SE, Adams MG, Kominiarek MA, et al. Reliability of a preventability model in maternal death and morbidity[J]. Am J Obstet Gynecol, 2007, 196(1):57. e1-e6.
[46]
王魏魏，姜婷，李春雨，等. 危重症孕产妇急救体系管理模式探讨[J/CD]. 中华卫生应急电子杂志，2016, 2(1):57-60.
[47]
MacKenzie IZ, Cooke I. What is a reasonable time from decision-to-delivery by caesarean section? Evidence from 415 deliveries[J]. BJOG, 2002, 109(5):498-504.
[48]
马可心，张为远. 紧急剖宫产术的决定手术至胎儿娩出时间[J]. 中华妇产科杂志，2017, 52(02):134-137.
[49]
李玉琴，郑博仁，王良山. 医疗团队资源管理模式在紧急剖宫产中的应用[J]. 中华妇产科杂志，2016, 51(8):631-633.
[50]
American College of Obstetricians and Gynecologists. Standards for obstetric services. 6th ed[M]. Washington, DC: ACOG, 1988.
[51]
National Institute for Health and Clinical Excellence (NICE). Caesarean section. Clinical Guideline[CG132][EB/OL]. NICE, (2012-08) [2017-09-30].

URL    
[52]
Kotarski J, Bobiński M. Decision-to-delivery interval (DDI) for emergency cesarean sections in Polish healthcare system[J]. Ginekol Pol, 2014, 85(6):451-455.
[53]
The Joint Commission. Preventing infant death and injury during delivery[J]. Jt Comm Perspect, 2004, 24(9):14-15.
[54]
World Health Organization. Beyond the numbers: reviewing maternal deaths and complications to make pregnancy safer. 2nd ed[M]. Geneva: WHO, 2004: 1-150.
[55]
Haddad SM, Cecatti JG, Parpinelli MA, et al. From planning to practice: building the national network for the surveillance of severe maternal morbidity[J]. BMC Public Health, 2011, 11:283.
[56]
Cecatti JG, Souza JP, Parpinelli MA, et al. Brazilian network for the surveillance of maternal potentially life threatening morbidity and maternal near-miss and a multidimensional evaluation of their long term consequences[J]. Reprod Health, 2009, 6:15.
[57]
Rana A, Baral G, Dangal G. Maternal near-miss: a multicenter surveillance in Kathmandu Valley[J]. JNMA J Nepal Med Assoc, 2013, 52(190):299-304.
[58]
Canadian Perinatal Surveillance System, Maternal Health Study Group. Special report on maternal mortality and severe morbidity in Canada: enhanced surveillance: the path to prevention[M]. Ottawa: Health Canada, 2004: 1-41.
[59]
Zwart JJ, Richters JM, Ory F, et al. Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: a nationwide population-based study of 371 000 pregnancies[J]. BJOG, 2008, 115(7):842-850.
[1] Shun Chen, Ensheng Xue, Qin Ye. Value of PDCA cycle in continuous improvement of ultrasonic critical value management system[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2023, 20(09): 974-978.
[2] Bohui Shi, Xiping Ding, Lian Wang, Rong Li, Pingli Guo, Jing Qi, Yao Chen, Na Hao, Yu Ren. Summary of best evidences for prevention and treatment of subcutaneous seroma after breast cancer surgery[J]. Chinese Journal of Breast Disease(Electronic Edition), 2023, 17(05): 277-284.
[3] Haoyuan Yang, Jie Gong, Qingwei Zou, Hang Ruan. Current research status on adverse pregnancy outcomes of maternal and infant in pregnant women with asthma[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2023, 19(05): 522-529.
[4] Roumei Cai, Jiemei Zeng, Weili Huang, Wenmin Xie, Yandan Liu, Manjun Wu, Chuyan Cai. Clinical research of QC circle intervention to reduce the incidence of catheter related infection during femoral vein catheterization in burn wounds[J]. Chinese Journal of Injury Repair and Wound Healing(Electronic Edition), 2023, 18(05): 399-404.
[5] Xiaojuan Li, Weijia Li, Lingyan Peng, Pengying Zhou, Gui'e Li, Xiangchen Liu. Analysis of the clinical characters of prostate calcification in physical examination population[J]. Chinese Journal of Endourology(Electronic Edition), 2023, 17(04): 336-338.
[6] Min Wang, Jiabin Jiang, Maoxin Li. Effect of early-warning education combined with personalized pain management on patients undergoing inguinal hernia surgery[J]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2023, 17(06): 764-767.
[7] Qingqing Zhu, Zhenqi Wei. Application value of self-efficacy management during perioperative period in patients with inguinal hernia[J]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2023, 17(06): 773-777.
[8] Xiaolan Min, Jiechao Zhou, Zhentian Chen. Effect of health management combined with psychological intervention in children after laparoscopic inguinal hernia surgery[J]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2023, 17(05): 657-661.
[9] Junyong Ma, Yizhou Wang, Xifeng Li. Brief discussion on prevention and control strategy for bleeding in laparoscopic hepatectomy[J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2023, 12(05): 495-498.
[10] . Expert consensus on perioperative management of day surgery for hip and knee arthroplasty in China[J]. Chinese Journal of Geriatric Orthopaedics and Rehabilitation(Electronic Edition), 2023, 09(06): 321-332.
[11] Jun Wang, Kunpeng Liu, Lan Yao, Hua Zhang, Yue Wei, Libin Suo, Jun Chen, chengli Miao, Chenghua Luo. Retrospective analysis of anesthesia management of massive transfusion patients undergoing retroperitoneal tumor resection[J]. Chinese Journal of Clinicians(Electronic Edition), 2023, 17(08): 844-849.
[12] Libin Suo, Kunpeng Liu, Lan Yao, Hua Zhang, Yue Wei, Jun Wang, Jun Chen, Chengli Miao, Chenghua Luo. Key points of anesthesia management and prognostic factors in patients undergoing primary retroperitoneal paraganglioma resection[J]. Chinese Journal of Clinicians(Electronic Edition), 2023, 17(07): 771-776.
[13] Guoxiao Xie, Lingxia Zhao, Xuehua Xue. Application of chronic disease management model in diabetes community management[J]. Chinese Journal of Clinicians(Electronic Edition), 2023, 17(05): 587-590.
[14] Xueyun Liu, Ying Fan, Aijun Yao, Shengmiao Zhang, Yani Lv, Bingqing Zhang, Xiaoyu Zhang, Heng. Liu. Effects of individualized whole-course nursing intervention based on WeChat mini program on pregnancy weight and delivery outcome[J]. Chinese Journal of Clinicians(Electronic Edition), 2023, 17(04): 455-460.
[15] Xuping Zhang, Jiacheng Liu, Ge Zhang, Yanjiao Du, Shao Li, Dandan Shang, Hao Wang, Yan Li, Zhihui Duan. CYP2C19 gene polymorphism combined with thromboelastogram-guided antiplatelet therapy for patients with the large artery atherosclerosis and non-disabling ischemic cerebrovascular events (NICE)[J]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2023, 17(05): 477-481.
Viewed
Full text


Abstract

Copyright © Chinese Medical Association, Chinese Medical Multimedia Press  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号