Defining severe maternal morbidity
SMM is more difficult to define than maternal death. Definitions proposed have included a woman so sick that she could have died but did not and a list of ICD-9 codes for severe illness during pregnancy, such as renal failure, cardiac failure, disseminated intravascular coagulation, pulmonary embolism, shock, and hysterectomy, among others.11,12,14 More recently, a diagnosis-based description of severe morbidity was proposed to aid in the determination of maternal severe illness.15 For example, a woman whose main diagnosis is hemorrhage would be considered to have SMM if she required 4 or more units of blood or required a procedure such as the Bakri balloon, uterine artery embolization, or hysterectomy to control her bleeding. If she only required 2 units of blood and no other procedures, it would not be considered to be SMM.
This system highlights the inherent subjectivity of the determination but at least offers a framework to guide evaluation of illness severity. Complete agreement between institutions as to what constitutes SMM is not necessary. Simply reviewing cases of patients who are locally deemed severely ill should provide insight into care and outcomes. Finally, as noted here, a simple mechanism to identify possible cases of SMM is to review all cases of pregnant or peripartum women who were transfused 4 or more units of blood or who were admitted to an intensive care unit (ICU), because these variables have high sensitivity and specificity for SMM.16,17 Here we illustrate how to review cases of SMM and show the benefits of such reviews.
Two examples of women with severe maternal morbidity
Case 1 is clearly a case of SMM, with uncontrolled hypertension and eclamptic seizure, although the patient ultimately did fine. Was the care she received, however, the best it could have been? This woman could have died. Would another woman managed in this same fashion survive or have even more severe maternal morbidity?
The detailed review of this case showed the actual timing of events. The patient initially received labetalol 5 mg IV push. Fifteen minutes after that dose, her repeat blood pressure was 190/115 mm Hg. She received a second dose of 5 mg IV labetalol, and 15 minutes later, her blood pressure was still 190/110 mm Hg. Thirty minutes later, her blood pressure was still elevated and she was given hydralazine 5 mg IV push. Magnesium was not started until after she had a seizure. After review, it was clear that the wrong doses and timing for labetalol were used. The correct dosing of labetalol is to begin with 20 mg and repeat every 15 minutes at double the dose.2 As well, she should have received magnesium sooner.
The review of this case should include evaluating provider issues, such as thought processes, documentation, and management and system issues. Was there timely and effective communication between nursing in triage and physicians? Was the diagnosis of severe preeclampsia made quickly? Why was the wrong dose of labetalol used? Did nursing question the dose? Why was magnesium not started sooner? The overall assessment for this case is that there were strong opportunities to improve care, and importantly, the review team should identify these opportunities to improve care.
Case 2 is clearly another case of SMM, with a major hemorrhage requiring 5 units of red blood cells and a hysterectomy. On detailed review of this case, the multidisciplinary review team found no opportunities for improvement in her current care and noted that the care team had planned carefully for the delivery, documented that plan, managed her acute hemorrhage according to their massive hemorrhage protocol, and that nursing had appropriately recognized the acute bleed and notified appropriate care givers urgently. The only opportunity for improved outcome would have been if she had not had an initial cesarean delivery.