Maternal severity of illness across levels of care: a prospective, cross-sectional study

The usefulness of a 28-item Therapeutic Intervention Scoring System (TISS-28) in critically ill obstetric patients to detect multiorgan dysfunction: A prospective cohort study

BACKGROUND

This study evaluated the effectiveness of the 28-item Therapeutic Intervention Scoring System (TISS-28) in detecting multiorgan dysfunction (MOD) among critically ill obstetric patients and compared its predictive potential to other severity models, such as Sequential Organ Failure Assessment (SOFA) and Mortality Probability Model II (MPM II).

METHODS

A prospective multicentre cohort study was conducted including obstetric patients, pregnant and up to 42 days postpartum, admitted to the intensive care units of two referral hospitals in Colombia. A total of 93 patients were recruited between March 2016 and February 2017 and from September 2019 to November 2019. Scores from the MPM II, SOFA, and TISS-28 were calculated within the first 24 h post-intensive care unit admission. The primary outcome was to evaluate the effectiveness of TISS-28 in predicting MOD, as defined by the World Health Organization near-miss criteria. We compared the TISS-28 with SOFA and MPM II scores in identifying MOD using the positive predictive value, negative predictive value, and the area under the receiver operating characteristic curve.

RESULTS

Data from 93 patients were analysed, of whom 22 developed MOD. Hypertensive disorders were the predominant diagnosis (n = 62; 66.7%). Patients with sepsis exhibited the highest TISS-28 score, indicating more intensive therapeutic interventions. The areas under the receiver operating characteristic curve for TISS-28, SOFA, and MPM II were 0.83 (95% confidence interval: 0.73-0.92), 0.66 (0.51-0.80), and 0.59 (0.43-0.74), respectively (p = 0.001). The cut-off value of a TISS-28 score ≥21 was associated with an increased likelihood of MOD (sensitivity: 83.2%, specificity: 71.2%), a positive predictive value of 47.3%, and a negative predictive value) of 93.2%.

CONCLUSIONS

TISS-28 demonstrated robust performance in identifying MOD among obstetric patients compared to other severity indexes. The TISS-28 score complements physiology-derived severity scores by reflecting the level of care required, making it a valuable tool in risk stratification and resource allocation for critically ill obstetric patients.

A scoping review of maternal near miss assessment in Australia, New Zealand, South-East Asia and the South Pacific region: How, what, why and where to?

BACKGROUND

Severe maternal morbidity or maternal near miss (MNM) events can have significant consequences for individuals, their families and society and the study of these events may inform practices to reduce future adverse pregnancy outcomes.

AIMS

To review the scope of MNM studies undertaken in Australia, New Zealand, South-East Asia and the South Pacific region.

MATERIALS AND METHODS

A systematic search of four online databases (MEDLINE, EMBASE, SCOPUS and CINAHL) and the World Health Organization Library was conducted to identify all relevant studies published between 1 January 2011 and 31 December 2020. The studies were reviewed and included if they assessed MNM using a composite outcome or a predefined set of indicators.

RESULTS

The literature search yielded 143 articles of which 49 are included in this review. There were substantial differences in the monitoring approach to MNM in the Australasian region. Overall rates of MNM in the region ranged from two to 100/1000 births and the most common aetiologies identified were direct obstetric causes such as postpartum haemorrhage, pre-eclampsia and sepsis. Multidisciplinary review indicated a substantial number of MNM cases were preventable or amenable to improved management, mostly from a provider perspective.

CONCLUSIONS

Assessment of MNM is an important part of the evaluation of maternity care provision. Reaching a consensus on indicators and how best to collect information will allow a more discerning assessment of MNM including longer-term health outcomes, aspects of preventability and financial implications for health services.

Maternity high-dependency care and the Australian midwife: A review of the literature

BACKGROUND

Maternity high-dependency care has emerged throughout the 21st century in Australian maternity hospitals as a distinct sub-speciality of maternity care. However, what the care involves, how and why it should be provided, and the role of midwives in the provision of such care remains highly variable.

INTRODUCTION

Rising levels of maternal morbidity from non-obstetric causes have led midwives to work with women who require highly complex care, beyond the standard customary midwifery role. Whilst the nursing profession has developed and refined its expertise as a specialty in the field of high-dependency care, the midwifery profession has been less likely to pursue this as a specific area of practice.

DISCUSSION

This paper explores the literature surrounding maternity high-dependency care. From the articles reviewed, four key themes emerge which include; the need for maternity high-dependency care, maternal morbidity and maternity high-dependency care, the role of the midwife and maternity high-dependency care and midwifery education and preparation for practice. It highlights the challenges that health services are faced with in order to provide maternity high-dependency care to women. Some of these challenges include resourcing and budgeting limitations, availability of educators with the expertise to train staff, and the availability of suitably trained staff to care for the women when required.

CONCLUSION

In order to provide maternity high-dependency care, midwives need to be suitably equipped with the knowledge and skills required to do so.

A fifteen-year retrospective review of obstetric patients requiring critical care

Background

Maternal mortality is a rare occurrence in developed nations. Given the low maternal mortality rate, other markers must be used to assess maternal risk and quality of obstetric care. One such is admission to critical care.

Aims

To determine the rate of admission, diagnosis and management of women from conception and up to 6 weeks postpartum to critical care units including coronary care (CCU), high dependency unit (HDU) and intensive care units (ICU).

Methods

We performed a retrospective review of obstetric patients requiring critical care admission from January 1995 to August 2010. Demographic details, obstetric history, place of admission (CCU, HDU or ICU) and fetal/neonatal outcomes were examined as were initial indication for critical care admission, final diagnosis and treatment administered.

Results

Data were available from 308 admission incidents. There were 259 (84%) admissions to ICU and 49 (15.9%) to CCU. More than a third of women were transferred from another institution. Those women transferred were more unwell and had a higher mortality rate than local women. Primary diagnoses: obstetric haemorrhage (ICU 30.9%), hypertensive disorders of pregnancy (ICU 16.2%, CCU 12.2%), infection (ICU 14.2%, CCU 6.1%), pre-existing cardiac disease (ICU 9.3%, CCU 55.1%).

Conclusions

The obstetric population represents only a small percentage of critical care utilisation and overall morbidity and mortality. However, this population is an important and growing group. Increased surveillance peripartum in a critical care facility allows earlier detection of maternal compromise and detailed management. Analysis of these 'near misses' in obstetrics aims to improve pregnancy outcomes.