Dedication

This humble effort is dedicated to my loving

Mother
Who is like my bridge, whenever I needed to get across; she steadied herself long enough for me by her constant efforts, love, affections and blessings to run across safely. Without your prayers, this work was

not possible. I dedicate this to you mom.

PREFACE
Carrying out an extensive study and managing to complete a dissertation on such a complicated and detailed topic that also highlights the efficiency of our prestigious Hospital LUMHS in saving unfortunate mothers from the edge of death and granting them a new life. That is what my research and study is about. Being a mother of four grown-up children, it wasnt easy as life is not always a bed of roses and so I had to put huge efforts and by the Grace of Almighty Allah my this much desirable goal has been achieved. And Im glad to say that I wasnt alone on my mission. My dear and respected Professor Firdous Mumtazs hand of blessing and guidance was always over my head. Most would agree that Professor Firdous Mumtaz is a beacon of light for her colleagues and a good example that one would gladly follow. I do too. She is one of those professors who pushes you to strive for your goals, inspires you, motivates you, guides you and so I would give my utmost and foremost thanks to her without whose support I may not be standing at this milestone.

Furthermore, my most loving daughter, Batool and my encouraging son, Burraq each put in extra hours of their own to give my rough drafts a presentable look by undertaking all the typing and printing jobs being thoroughly patient at the same time with their constant encouragement fuelling me up and giving me the strength and confidence to complete this humble effort. So for this service, I would like to thank my children and let them know how much I appreciate their patience, hard work and encouragement. And how can I forget my loving husband who with all his patience gave me the peace of mind and time I required not uttering one word of disencouragement. Therefore, I would like to say Thank you Aslam. Also my profound gratitude for my fellow colleagues who helped me with discussions and careful advice. I would particularly thank Dr. Nosheen Aziz who encouraged me and always pushed me up to achieve my aim in the beginning of my training period. Last but not the least; I would like to acknowledge my patients who took part in this study.

CONTENTS
S# A B C D E F Supervisor`s Certificate Dedication Preface List of Contents List of Tables List of Abbreviations 1 Abstract . TITLE PAGE #

2 Introduction .

3 Study Rationale .

4 Historical Background and Review of Literature .

5 Clinical Aspect .

6 Methodology Material & Method Study Setting .

7 Results .

8 Tables .

9 Discussion .

1 Conclusions 0 .

1 Recommendations 1 .

1 Limitations 2 .

1 References 3 .

LIST OF TABLES
Tabl e 1 2 Risk Factors For Near Miss Demographic and Socioeconomic Factors Associated with Near miss 3 4 5 6 7 8 9 Causes associated with Near miss (SAMM) Number of Blood Transfusions and Blood Products Characteristics of Obstetric admissions to ICU Surgical Interventions Maternal Outcome Fetal Outcome Five Factors associated Weighted Scoring System TITLE PAGE #

LIST OF ABBREVIATONS

PPH APH WHO C/S NVD LUH TBA SAMM MMR AMTSL ICU CNS LFT Mgso4 PGF2 UNDP UNFPA

Postpartum hemorrhage Ante partum hemorrhage World Health Organization Caesarian Section Normal Vaginal Delivery Liaquat University Hospital Traditional Birth Attendant Severe Acute Maternal Morbidity Maternal Mortality Rate Active Management of Third Stage of Labor Intensive Care Unit Central Nervous System Liver Function Test Magnesium Sulfate Prostaglandin F2 alpha United Nations Development Program United Nations Fund for Population Activities

ABSTRACT
AIMS AND OBJECTIVES To find out the frequency and pattern of near miss cases (critically ill obstetric

patients) in obstetrics and gynecology unit II, Liaquat University Hospital. To find out the associated factors leading to critical illness in obstetric patients

in our set up. STUDY DESIGN Prospective observational

PLACE AND DURATION OF STUDY Department of obstetrics and gynecology unit II, Liaquat University of medical and health sciences hospital, Hyderabad from 1st June 2011 to 30th November 2011. SUBJECTS AND METHODS All pregnant, laboring and postpartal who were brought to our obstetric ward in critical condition or developed illness in hospital were included in this study. Factors leading to these critically ill patients were found out using criteria for near miss cases suited to the diagnostic and treatment facilities available in the hospital setting. For each case of near miss (SAMM) a proforma was used. Results were analyzed through computer software programme SPSS version 17 and percentages were used to describe the date. RESULTS Total no. of obstetric admission during the study period was 3296 out of these 150 (4.6%) were near miss cases. The commonest obstetric diagnosis in this study was hemorrhage, followed by eclampsia, puerpeural sepsis. The commonest intervention

done was C/S, then _blood transfusion and shifting to ICU. The commonest organ systems involved were Respiratory system, Hemodynamic system and Renal system. CONCLUSION Majority of near miss cases were due to hemorrhage & hypertensive disorders. Most of the women in Pakistan still do not realize the significance of antenatal care and therefore seek no advice and treatment during pregnancy. Lot of private maternity homes and clinics are run by dais, nurses and even untrained doctors who either are unable to diagnose the complication or diagnosis and referral to hospital is very late. KEY WORDS Severe acute maternal morbidity, near miss hemorrhage, eclampsia, sepsis, obstetrical hysterectomy.