BACKGROUND: To evaluate whether the introduction of a strict protocol based on the systemic
evaluation of critically ill pregnant women with complications of hypertension affected the outcome
of those women.
METHOD: Study group: Indigent South African women managed in the tertiary hospitals of the
Pretoria Academic Complex. Since 1997 a standard definition of women with severe acute
maternal morbidity (SAMM), also referred to as a Nearmiss, has been used in the Pretoria
Academic Complex. All cases of SAMM and maternal deaths (MD) were entered on the Maternal
Morbidity and Mortality Audit System programme (MaMMAS). A comparison of outcome of
severely ill women who had complications of hypertension in pregnancy was performed between
1997–1998 (original protocol) and 2002–2003 (strict protocol). Data include women referred from
outside the Pretoria Academic Complex area to the tertiary hospitals.
RESULTS: Between 1997–1998 there were 79 women with SAMM and 18 maternal deaths due to
complications of hypertension, compared with 91 women with SAMM and 13 maternal deaths in
2002–2003. The mortality index (MI) declined from 18.6% to 12.5% (OR 0.62, 95% CI 0.27–1.45).
Statistically significant fewer women had renal failure (RR 0.37, 95% CI 0.21 – 0.66) and cerebral
complications (RR 0.52, 95%CI 0.34 – 0.81) during the second period, and liver dysfunction (RR
0.27 95%CI 0.06 – 1.25) tended to be lower. However, there tended to be an increase in the
number of women, who had immune system failure (RR 4.2 95%CI 0.93 – 18.94) and respiratory
failure (RR 1.42 95%CI 0.88 – 2.29) although it did not reach significance. Cardiac failure remained
constant (RR 0.84 95%CI 0.54 – 1.30).
CONCLUSION: The strict protocol approach based on the systemic evaluation of severely ill
pregnant women with complications of hypertension and an intensive, regular feedback mechanism
has been associated with a reduction in the number of patients with renal failure and cerebral