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Polprasarn P, Thongwon T. Modified Early Obstetric Warning Criteria Predict Maternal Morbidity in the Immediate Postpartum Period: A Case-Control Study. Nurs Womens Health 2023; 27:407-415. [PMID: 37837995 DOI: 10.1016/j.nwh.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/03/2023] [Accepted: 09/13/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVE To evaluate the application of Modified Early Obstetric Warning Criteria (MEOWC) in the immediate postpartum period and to generate a preliminary predictive model for postpartum maternal morbidity. DESIGN Retrospective case-control study that was conducted from January 2017 to January 2020. A total of 2,762 births occurred during the study period. SETTING Obstetrics unit of a general hospital located in the Nakhon Si Thammarat province of Thailand. PARTICIPANTS Three hundred charts of complete health records for women in the first 24 hours postbirth were used in the study. Severe maternal morbidity indicators from the Centers for Disease Control and Prevention as well as corresponding International Classification of Diseases, 10th Revision-Clinical Modification codes during birth and postpartum hospitalizations were used to define maternal morbidity. Case and control individuals were matched in an approximate 1:2 fashion based on the year when the birth occurred. MEASUREMENTS Outcomes measurement was carried out using three data record forms-personal data, obstetric history, and MEOWC. To estimate the risks, logistic regression was performed, and a receiver operating characteristic curve was derived to evaluate the model's performance. RESULTS One hundred cases of maternal morbidity that occurred in the immediate postpartum period were identified and matched with 200 control cases. Women with MEOWC during the immediate postpartum were much more likely to experience subsequent postpartum maternal morbidity than were women without the criteria. MEOWC were a moderate predictor of postpartum maternal morbidity. CONCLUSION MEOWC are associated with increased odds of postpartum maternal morbidity. However, these findings should be validated in a prospective cohort to develop a predictive model that is effective for use in immediate postpartum care.
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Yadav P, Sinha R. Validating the Performance of Modified Early Obstetrics Warning Score (MEOWS) for Prediction of Obstetrics Morbidity: A Prospective Observational Study in a Tertiary Care Institute in East India. J Obstet Gynaecol India 2023; 73:227-233. [PMID: 38143979 PMCID: PMC10746593 DOI: 10.1007/s13224-023-01855-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/01/2023] [Indexed: 12/26/2023] Open
Abstract
Background An early warning score can be used to identify worsening in obstetric patients as they are more prone for deterioration. This study was conducted to evaluate and validate the performance of the modified early obstetric warning system (MEOWS) as a screening tool for early prediction of severe obstetric morbidity. Methods This prospective observational study was conducted at obstetrics and gynaecology department, Tata Main Hospital, Jamshedpur, Jharkhand, India. A total of 1800 patients were included over a period of 10 month, from December 2021 to September 2022. Study population included all pregnant women admitted in labour room with > 28 weeks of gestation till 6 weeks postpartum. MEOWS charts were plotted for each patient, score calculated and documented at admission. Patients were categorized based on this score for further management, and follow-up was made till discharge. Outcome assessment was done in terms of ICU admission, length of hospital stays, obstetric morbidity, and maternal mortality. Correlation of each outcome with scoring was evaluated. Results The sensitivity of MEOWS in predicting maternal morbidity was 72.91%, specificity 91.87%, positive predictive value 85.96%, and negative predictive value 83.24%. The area under receiver operator characteristic of MEOWS for prediction of maternal mortality was 0.79 (95% CI 0.75-0.82). Conclusion MEOWS helps in early recognition of obstetric morbidity even before signs, and symptoms become clinically evident. It is a useful tool for predicting adverse maternal outcome in pregnant women.
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Affiliation(s)
- Preeti Yadav
- Dept of Obs & Gynae Specialist, Tata Main Hospital, Jamshedpur, Jharkhand India
| | - Ranjana Sinha
- Department of Obstetrics and Gynaecology, Tata Main Hospital, Jamshedpur, Jharkhand India
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Gupta C, Suri J, Bachani S, Bharti R, Pandey D, Mittal P. Carle's obstetric early warning score as a screening tool for critical care admission. Indian J Med Res 2023; 158:339-346. [PMID: 37988032 DOI: 10.4103/ijmr.ijmr_2478_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND OBJECTIVES Early warning systems (EWS) involve serial observations (track) with criteria (trigger) to timely identify patients at risk of complications. Carle designed a statistically based clinically modified obstetric early warning score (Carle's OEWS). This study evaluated Carle's OEWS and its individual components for predicting admission to the obstetric critical care unit (OCCU). Maternal near-miss and maternal mortality were the secondary outcomes. METHODS A prospective observational study was conducted among 1250 pregnant women with a period of gestation ≥28 week admitted in the labour wards of a tertiary centre over 18 months. The physiological parameters of OEWS were recorded and aggregate score was calculated at admission and at regular intervals thereafter, till discharge or OCCU admission. RESULTS The area under receiver operating characteristic (ROC) curve of OEWS was 0.975 for predicting OCCU admission, 0.971 for near-miss, and 0.996 for predicting maternal mortality and was significant for all outcomes. All individual parameters, except diastolic blood pressure, had a significant relative risk for predicting OCCU requirement. INTERPRETATION CONCLUSIONS Carle's OEWS is a useful screening tool for predicting obstetric OCCU admission and can be routinely used in labour wards to ensure timely intervention.
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Affiliation(s)
- Chhavi Gupta
- Department of Obstetrics & Gynaecology, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
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Ayala Quintanilla BP, Taft A, McDonald S, Pollock W, Roque Henriquez JC. Social determinants and exposure to intimate partner violence in women with severe acute maternal morbidity in the intensive care unit: a systematic review. BMC Pregnancy Childbirth 2023; 23:656. [PMID: 37700244 PMCID: PMC10496274 DOI: 10.1186/s12884-023-05927-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/16/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Studying severe acute maternal morbidity in the intensive care unit improves our understanding of potential factors affecting maternal health. AIM To review evidence on maternal exposure to intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit. METHODS The protocol for this review was registered in PROSPERO (registration number CRD42016037492). A systematic search was performed in MEDLINE, CINAHL, ProQuest, LILACS and SciELO using the search terms "intensive care unit", "intensive care", "critical care" and "critically ill" in combination with "intimate partner violence", "social determinants of health", "severe acute maternal morbidity", pregnancy, postpartum and other similar terms. Eligible studies were (i) quantitative, (ii) published in English and Spanish, (iii) from 2000 to 2021, (iv) with data related to intimate partner violence and/or social determinants of health, and (v) investigating severe acute maternal morbidity (maternity patients treated in the intensive care unit during pregnancy, childbirth or within 42 days of pregnancy termination). Of 52,866 studies initially identified, 1087 full texts were assessed and 156 studies included. Studies were independently assessed by two reviewers for screening, revision, quality assessment and abstracted data. Studies were categorised into high/middle/low-income countries and summarised data were presented using a narrative description, due to heterogenic data as: (i) exposure to intimate partner violence and (ii) social determinants of health. RESULTS One study assessed intimate partner violence among mothers with severe acute maternal morbidity in the intensive care unit and found that women exposed to intimate partner violence before and during pregnancy had a nearly four-fold risk of severe acute maternal morbidity requiring ICU admission. Few social determinants of health other than age were reported in most studies. CONCLUSION This review identified a significant gap in knowledge concerning intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit, which is essential to better understand the complete picture of the maternal morbidity spectrum and reduce maternal mortality.
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Affiliation(s)
- Beatriz Paulina Ayala Quintanilla
- School of Nursing and Midwifery, The Judith Lumley Centre, La Trobe University, Plenty Road & Kingsbury Drive, Level 3, George Singer Building, Bundoora, Melbourne, VIC, Australia.
- Universidad de San Martin de Porres, La Molina, Lima, Peru.
| | - Angela Taft
- School of Nursing and Midwifery, The Judith Lumley Centre, La Trobe University, Plenty Road & Kingsbury Drive, Level 3, George Singer Building, Bundoora, Melbourne, VIC, Australia
| | - Susan McDonald
- School of Nursing and Midwifery, The Judith Lumley Centre, La Trobe University, Plenty Road & Kingsbury Drive, Level 3, George Singer Building, Bundoora, Melbourne, VIC, Australia
| | - Wendy Pollock
- School of Nursing and Midwifery, The Judith Lumley Centre, La Trobe University, Plenty Road & Kingsbury Drive, Level 3, George Singer Building, Bundoora, Melbourne, VIC, Australia
- Nursing and Midwifery, Monash University, Melbourne, VIC, Australia
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Kaur J, Thompson C, McLeod S, Varner C. Application of the Modified Early Obstetrical Warning System (MEOWS) in postpartum patients in the emergency department. CAN J EMERG MED 2023:10.1007/s43678-023-00500-7. [PMID: 37088841 DOI: 10.1007/s43678-023-00500-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/24/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Over the last two decades, there has been a steady rise in severe maternal morbidity and pregnancy-related deaths in Canada and the USA. The Modified Early Obstetric Warning System (MEOWS) is a risk stratification tool designed to predict severe maternal morbidity and mortality and has been validated for use in obstetrical wards. The objective of this study was to determine if MEOWS could accurately identify patients at risk of severe maternal morbidity and mortality in the ED setting. METHODS This was a chart review of patients presenting to an academic tertiary care centre (annual ED census 65,000) with a postpartum complaint within 6 weeks of delivery between May 2020 and March 2022. The exposure was the presence of a trigger, defined as one severely abnormal (red) or two mildly abnormal (yellow) physiological measurements during the ED visit. The diagnostic accuracy of the tool to identify patients at risk of severe maternal morbidity severe maternal morbidity or mortality was estimated by calculating the sensitivity, specificity, positive predictive value and negative predictive value. RESULTS Two hundred and sixty-seven patients were included, of which 21 (7.9%) met the criteria for severe maternal morbidity. There were no maternal deaths. Overall, the sensitivity of the MEOWS tool was 85.7% (95% CI 63.7-97.0%), specificity was 67.9% (95% CI 61.7-73.7%), positive predictive value was 18.6% (95% CI 15.1-22.7%), and negative predictive value was 98.2% (95% CI 95.1-99.4%). Severe preeclampsia and eclampsia were the most common outcome category of severe maternal morbidity, representing 16 (76.2%) cases. Most patients (86.5%) were discharged directly from the ED, and 90.0% did not return within 30 days. CONCLUSIONS This study is the first to explore the utility of MEOWS in postpartum ED patients. The presence of a MEOWS trigger at ED triage or the first ED nursing assessment was associated with severe maternal morbidity. Thus, MEOWS may be a valuable tool to identify postpartum patients at risk of severe outcomes early in an ED visit.
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Affiliation(s)
- Jeeventh Kaur
- Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada
| | - Cameron Thompson
- Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada
- Sinai Health, Toronto, ON, Canada
| | - Shelley McLeod
- Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada
- Sinai Health, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Catherine Varner
- Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada.
- Sinai Health, Toronto, ON, Canada.
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
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A new modified obstetric early warning score for prognostication of severe maternal morbidity. BMC Pregnancy Childbirth 2022; 22:901. [PMID: 36464694 PMCID: PMC9720996 DOI: 10.1186/s12884-022-05216-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 11/13/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Maternal mortality is still a major challenge for health systems, while severe maternal complications are the primary causes of maternal death. Our study aimed to determine whether severe maternal morbidity is effectively predicted by a newly proposed Modified Obstetric Early Warning Score (MOEWS) in the setting of an obstetric intensive care unit (ICU). METHODS A retrospective study of pregnant women admitted in the ICU from August 2019 to August 2020 was conducted. MOEWS was calculated 24 h before and 24 h after admission in the ICU, and the highest score was taken as the final value. For women directly admitted from the emergency department, the worst value before admission was collected. The aggregate performance of MOEWS in predicting critical illness in pregnant women was evaluated and finally compared with that of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score. RESULTS A total of 352 pregnant women were enrolled; 290 women (82.4%) with severe maternal morbidity were identified and two of them died (0.6%). The MOEWSs of women with serious obstetric complications were significantly higher than those of women without serious obstetric complications [8(6, 10) vs. 4(2, 4.25), z = -10.347, P < 0.001]. MOEWSs of 24 h after ICU admission had higher sensitivity, specificity and AUROC than MOEWSs of 24 h before ICU admission. When combining the two MOEWSs, sensitivity of MOEWS was 99.3% (95% CI: 98-100), specificity 75.8% (95% CI: 63-86), positive predictive value (PPV) 95.1% (95% CI: 92-97) and negative predictive value (NPV) 95.9% (95% CI: 86-100). The areas under the receiver operator characteristic (ROC) curves of MOEWS were 0.92 (95% CI: 0.88-0.96) and 0.70 (95% CI: 0.63-0.76) of the APACHE II score. CONCLUSION The newly proposed MOEWS has an excellent ability to identify critically ill women early and is more effective than APACHE II. It will be a valuable tool for discriminating severe maternal morbidity and ultimately improve maternal health.
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Escobar MF, Echavarria MP, Gallego JC, Riascos N, Vasquez H, Nasner D, Pabon S, Castro ZA, Cardona DA, Castro AM, Ramos I, Hincapie MA, Kusanovic JP, Martínez-Ruíz DM, Carvajal JA. Effect of a model based on education and teleassistance for the management of obstetric emergencies in 10 rural populations from Colombia. Digit Health 2022; 8:20552076221129077. [PMID: 36204705 PMCID: PMC9530555 DOI: 10.1177/20552076221129077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 09/11/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Pregnant women and health providers in rural areas of low-income and middle-income countries face multiple problems concerning high-quality obstetric care. This study was performed to identify changes in maternal and perinatal indicators after implementing a model based on education and telecare between a high-complexity hospital in 10 low-complexity hospitals in a southwestern region of Colombia. Methods A quasiexperimental study with a historic control group and without a pretest was conducted between 2017 and 2019 to make comparisons before and after obstetric emergency care through the use of teleassistance from 10 primary care centers to the referral center (Fundación Valle del Lili, FVL). Results A total of 470 patients were treated before teleassistance implementation and 154 patients were treated after teleassistance implementation. After program implementation, the maternal clinical indicators showed a 65% reduction in the number of obstetric patients who were referred with obstetric emergencies. The severity of maternal disease that was measured at the time of admission to level IV through the Modified Early Obstetric Warning System score was observed to decrease. Conclusion The implementation of a model based on education and teleassistance between low-complexity hospitals and tertiary care centers generated changes in indicators that reflect greater access to rural areas, lower morbidity at the time of admission, and a decrease in the total number of emergency events.
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Affiliation(s)
- María Fernanda Escobar
- High Complexity Obstetric Unit, Department of Obstetrics and
Gynecology, Fundación Valle del Lili, Cali, Colombia,Department of Telemedicine, Fundación Valle del Lili, Cali, Colombia,María Fernanda Escobar Vidarte, Fundación
Valle del Lili. Cra 98 Nro.18-49 Cali 760032, Colombia. Emails:
;
| | - María Paula Echavarria
- High Complexity Obstetric Unit, Department of Obstetrics and
Gynecology, Fundación Valle del Lili, Cali, Colombia,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Juan Carlos Gallego
- High Complexity Obstetric Unit, Department of Obstetrics and
Gynecology, Fundación Valle del Lili, Cali, Colombia,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Natalia Riascos
- High Complexity Obstetric Unit, Department of Obstetrics and
Gynecology, Fundación Valle del Lili, Cali, Colombia,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Hilda Vasquez
- Department of Telemedicine, Fundación Valle del Lili, Cali, Colombia
| | - Daniela Nasner
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali,
Colombia
| | - Stephanie Pabon
- High Complexity Obstetric Unit, Department of Obstetrics and
Gynecology, Fundación Valle del Lili, Cali, Colombia
| | - Zindy Alexandra Castro
- High Complexity Obstetric Unit, Department of Obstetrics and
Gynecology, Fundación Valle del Lili, Cali, Colombia
| | - Didier Augusto Cardona
- High Complexity Obstetric Unit, Department of Obstetrics and
Gynecology, Fundación Valle del Lili, Cali, Colombia
| | - Ana Milena Castro
- Department of Telemedicine, Fundación Valle del Lili, Cali, Colombia
| | - Isabella Ramos
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - María Antonia Hincapie
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Juan Pedro Kusanovic
- Department of Obstetrics and Gynecology, Center for Research and
Innovation in Maternal-Fetal Medicine (CIMAF), Hospital Sótero del Río, Santiago,
Chile,Division of Obstetrics and Gynecology, School of Medicine,
Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Javier Andrés Carvajal
- High Complexity Obstetric Unit, Department of Obstetrics and
Gynecology, Fundación Valle del Lili, Cali, Colombia,Department of Telemedicine, Fundación Valle del Lili, Cali, Colombia
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Ahmed SI, Khowaja BMH, Barolia R, Sikandar R, Rind GK, Khan S, Rani R, Cheshire J, Dunlop CL, Coomarasamy A, Sheikh L, Lissauer D. Adapting the FAST-M maternal sepsis intervention for implementation in Pakistan: a qualitative exploratory study. BMJ Open 2022; 12:e059273. [PMID: 36691196 PMCID: PMC9472171 DOI: 10.1136/bmjopen-2021-059273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 08/08/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE A maternal sepsis management bundle for resource-limited settings was developed through a synthesis of evidence and international consensus. This bundle, called 'FAST-M' consists of: Fluids, Antibiotics, Source control, assessment of the need to Transport/Transfer to a higher level of care and ongoing Monitoring (of the mother and neonate). The study aimed to adapt the FAST-M intervention including the bundle care tools for early identification and management of maternal sepsis in a low-resource setting of Pakistan and identify potential facilitators and barriers to its implementation. SETTING The study was conducted at the Liaquat University of Medical and Health Sciences, which is a tertiary referral public sector hospital in Hyderabad. DESIGN AND PARTICIPANTS A qualitative exploratory study comprising key informant interviews and a focus group discussion was conducted with healthcare providers (HCPs) working in the study setting between November 2020 and January 2021, to ascertain the potential facilitators and barriers to the implementation of the FAST-M intervention. Interview guides were developed using the five domains of the Consolidated Framework for Implementation Research: intervention characteristics, outer setting, inner setting, characteristics of the individuals and process of implementation. RESULTS Four overarching themes were identified, the hindering factors for implementation of the FAST-M intervention were: (1) Challenges in existing system such as a shortage of resources and lack of quality assurance; and (2) Clinical practice variation that includes lack of sepsis guidelines and documentation; the facilitating factors identified were: (3) HCPs' perceptions about the FAST-M intervention and their positive views about its execution and (4) Development of HCPs readiness for FAST-M implementation that aided in identifying solutions to potential hindering factors at their clinical setting. CONCLUSION The study has identified potential gaps and probable solutions to the implementation of the FAST-M intervention, with modifications for adaptation in the local context TRIAL REGISTRATION NUMBER: ISRCTN17105658.
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Affiliation(s)
| | | | - Rubina Barolia
- School of Nursing and Midwifery, Aga Khan University, Karachi, Pakistan
| | - Raheel Sikandar
- Obstetrics and Gynecology, Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan
| | - Ghulam Kubra Rind
- Obstetrics and Gynecology, The Aga Khan University, Karachi, Pakistan
| | - Sehrish Khan
- Obstetrics and Gynecology, Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan
| | - Raheela Rani
- Obstetrics and Gynecology, Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan
| | - James Cheshire
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | | | - Arri Coomarasamy
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Lumaan Sheikh
- Obstetric & Gynecology, The Aga Khan University Hospital, Karachi, Pakistan
| | - David Lissauer
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
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Escobar MF, Echavarria MP, Vasquez H, Nasner D, Ramos I, Hincapié MA, Pabon S, Kusanovic JP, Martínez-Ruíz DM, Carvajal JA. Experience of a telehealth and education program with maternal and perinatal outcomes in a low-resource region in Colombia. BMC Pregnancy Childbirth 2022; 22:604. [PMID: 35906534 PMCID: PMC9336139 DOI: 10.1186/s12884-022-04935-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/19/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Maternal morbidity and mortality rates associated with perinatal care remain a significant public health concern. Rural populations from low and middle-income countries have multiple barriers to access that contribute to a lack of adherence to prenatal care, and high rates of maternal mortality and morbidity. An intervention model based on telehealth and education was implemented between a tertiary high complex care hospital and a second-level hospital from a limited source region. OBJECTIVES We sought to identify an association in maternal and perinatal care quality indicators after implementing a model based on telehealth and education for patients with obstetric emergencies between two hospitals in a southwestern region of Colombia. METHODS We conducted an ecological study between 2017 and 2019 to compare before and after obstetric emergency care through telemedicine from a secondary care center (Hospital Francisco de Paula Santander-HFPS) to the referral center (Fundación Valle del Lili-FVL). The intervention included verification visits to determine the installed capacity of care, a concerted improvement plan, and on-site educational training modules in obstetric and perinatal care. RESULTS There were 102 and 148 patients treated before and after telemedicine implementation respectively. Clinical indicators after model implementation showed a reduction in perinatal mortality of 29%. In addition, a reduction in the need for transfusion of blood products due to postpartum hemorrhage was observed as well as the rate of eclampsia. CONCLUSIONS Implementing a model based on telehealth and education between secondary and tertiary care centers allowed the strengthening of the security of care in obstetric emergencies and had a positive effect on perinatal mortality.
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Affiliation(s)
- María Fernanda Escobar
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia.
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia.
- Department of Telemedicine, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia.
| | - María Paula Echavarria
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Hilda Vasquez
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
- Department of Telemedicine, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
| | - Daniela Nasner
- Department of Telemedicine, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
| | - Isabella Ramos
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - María Antonia Hincapié
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Stephanie Pabon
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
| | - Juan Pedro Kusanovic
- Department of Obstetrics and Gynecology, Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF), Hospital Sótero del Río, Santiago, Chile
- Division of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Javier Andrés Carvajal
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
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10
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Smith V, O'Malley D, Cithambaram K. Early warning systems in maternity care: A qualitative evidence synthesis of maternity care providers' views and experiences. Midwifery 2022; 112:103402. [PMID: 35724435 DOI: 10.1016/j.midw.2022.103402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 06/05/2022] [Accepted: 06/07/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To gain insight and understanding, from the perspective of maternity care providers, on the use and application of maternity early warning systems (MEWS) in clinical practice. DESIGN A qualitative evidence synthesis was conducted. MEDLINE, CINHAL, Web of Science Core Collection and Maternity and Infant Care (MIDIRS), from inception to March 2021, were searched for eligible studies. Grey literature sources were also searched for unpublished studies. The methodological quality of included studies was assessed by at least two reviewers using an Evidence for Policy and Practice Information and Co-ordinating (EPPI) Centre quality assessment tool. Thomas and Harden's thematic synthesis approach was used to guide the data synthesis. Confidence in the findings was assessed using the Grading of Recommendations Assessment, Development and Evaluation of Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual). SETTING AND PARTICIPANTS Included studies reported on maternity care providers involved in caring for pregnant or postpartum women in any birth setting. Studies were mostly qualitative in design, although survey designs with open-ended questions that provided qualitative data were eligible for inclusion if the qualitative data had been subjected to formal analyses. FINDINGS Eight eligible studies, reported across nine records, were identified in the search and included in the review. Three themes representative of maternity care providers' views and experiences of MEWS were generated from the synthesis. These were 'Aid to clinical care provision', 'Impact on workload' and 'Factors affecting MEWS implementation'. MEWS was viewed as a useful tool in guiding clinical care, and for identifying deterioration and the need to escalate care. Some maternity care providers viewed MEWS as beneficial in easing workload burden. Others, however, viewed MEWS as adding to workload because of repetition and duplication. Training in MEWS was considered inadequate and concern existed for some care providers that MEWS would lead to deskilling or eroding of professional judgement. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Maternity care providers hold diverse views on the use of MEWS in clinical practice. While almost all consider MEWS a helpful aid for guiding clinical care, barriers to implementation were identified. These included added workload burden, inadequate training, and concern for deskilling. Attending to implementation barriers will help optimise use of MEWS in clinical practice as currently recommended.
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Affiliation(s)
- Valerie Smith
- School of Nursing and Midwifery, University of Dublin Trinity College, 24 D'Olier Street, Dublin, Ireland.
| | - Deirdre O'Malley
- Department of Nursing, Midwifery and Early Years, School of Health and Science, Dundalk Institute of Technology, Ireland
| | - Kumaresan Cithambaram
- School of Nursing, Psychotherapy and Community Health, Dublin City University, Dublin, Ireland
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Abstract
Maternal morbidity and mortality are rising due in part to the rising prevalence of chronic illness, socioeconomic and racial disparities, and advanced maternal age. Prevention of maternal adverse outcomes requires prompt escalation of care to facilities with appropriate capabilities including intensive care services. The development of obstetrical-specific risk assessment tools and protocolized care for the most common causes of maternal intensive care unit (ICU) admission has helped to reduce preventable complications. However, significant work remains to address barriers to the escalation of maternal care and minimize delays in appropriate management.
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Affiliation(s)
- Elisa C Walsh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 444, Boston, MA 02114, USA
| | - Emily E Naoum
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 444, Boston, MA 02114, USA.
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12
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Smith V, Kenny LC, Sandall J, Devane D, Noonan M. Physiological track-and-trigger/early warning systems for use in maternity care. Cochrane Database Syst Rev 2021; 9:CD013276. [PMID: 34515991 PMCID: PMC8436732 DOI: 10.1002/14651858.cd013276.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND A considerable challenge for maternity care providers is recognising clinical deterioration early in pregnant women. Professional bodies recommend the use of clinical assessment protocols or evaluation tools, commonly referred to as physiological track-and-trigger systems (TTS) or early warning systems (EWS), as a means of helping maternity care providers recognise actual or potential clinical deterioration early. TTS/EWS are clinician-administered (midwife, obstetrician), bedside physiological assessment protocols, charts or tools designed to record routinely assessed clinical parameters; that is, blood pressure, temperature, heart rate, urine output and mental/neurological alertness. In general, these systems involve the application of scores or alert indicators to the observed physiological parameters based on their prespecified limits of normality. The overall system score or alert limit is then used to assist the maternity care provider identify a need to escalate care. This, in turn, may allow for earlier intervention(s) to alter the course of the emerging critical illness and ultimately reduce or avoid mortality and morbidity sequelae. OBJECTIVES To evaluate the clinical- and cost-effectiveness of maternal physiological TTS/EWS on pregnancy, labour and birth, postpartum (up to 42 days) and neonatal outcomes. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (28 May 2021), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (7 June 2021), OpenGrey, the ProQuest Dissertations and Theses database (7 June 2021), and reference lists of retrieved studies. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials (RCTs), including cluster-RCTs, comparing physiological TTS/EWS with no system or another system. Participants were women who were pregnant or had given birth within the previous 42 days, at high risk and low risk for pregnancy, labour and birth, and postpartum complications. DATA COLLECTION AND ANALYSIS Two review authors (VS and MN) independently assessed all identified papers for inclusion and performed risk of bias assessments. Any discrepancies were resolved through discussion and consensus. Data extraction was also conducted independently by two review authors (VS and MN) and checked for accuracy. We used the summary odds ratio (OR) with 95% confidence intervals (CIs) to present the results for dichotomous data and the mean difference (MD) with 95% CI to present the results for continuous data. MAIN RESULTS We included two studies, a parallel RCT involving 700 women and a stepped-wedge cluster trial involving 536,233 women. Both studies were published in 2019, and both were conducted in low-resource settings. The interventions were the 'Saving Mothers Score' (SMS) and the CRADLE Vital Sign Alert (VSA) device, and both interventions were compared with standard care. Both studies had low or unclear risk of bias on all seven risk of bias criteria. Evidence certainty, assessed using GRADE, ranged from very low to moderate certainty, mainly due to other bias as well as inconsistency and imprecision. For women randomised to TTS/EWS compared to standard care there is probably little to no difference in maternal death (OR 0.80, 95% CI 0.30 to 2.11; 1 study, 536,233 participants; moderate-certainty evidence). Use of TTS/EWS compared to standard care may reduce total haemorrhage (OR 0.36, 95% CI 0.19 to 0.69; 1 study, 700 participants; low-certainty evidence). For women randomised to TTS/EWS compared to standard care there may be little to no difference in sepsis (OR 0.21, 95% CI 0.02 to 1.80; 1 study, 700 participants; low-certainty evidence), eclampsia (OR 1.50, 95% CI 0.74 to 3.03; 2 studies, 536,933 participants; low-certainty evidence) and HELLP (OR 0.21, 95% CI 0.01 to 4.40; 1 study, 700 participants; very low-certainty evidence), and probably little to no difference in maternal admission to the intensive care unit (ICU) (OR 0.78, 95% CI 0.53 to 1.15; 2 studies, 536,933 participants; moderate-certainty evidence). Use of TTS/EWS compared to standard care may reduce a woman's length of hospital stay (MD -1.21, 95% CI -1.78 to -0.64; 1 study, 700 participants; low-certainty evidence) but may result in little to no difference in neonatal death (OR 1.06, 95% CI 0.62 to 1.84; 1 study, 700 participants; low-certainty evidence). Cost-effectiveness measures were not measured in either of the two studies. AUTHORS' CONCLUSIONS: Use of TTS/EWS in maternity care may be helpful in reducing some maternal outcomes such as haemorrhage and maternal length of hospital stay, possibly through early identification of clinical deterioration and escalation of care. The evidence suggests that the use of TTS/EWS compared to standard care probably results in little to no difference in maternal death and may result in little to no difference in neonatal death. Both of the included studies were conducted in low-resource settings where the use of TTS/EWS might potentially confer a different effect to TTS/EWS use in high-resource settings. Further high-quality trials in high- and middle-resource settings, as well as in discrete populations of high- and low-risk women, are required.
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Affiliation(s)
- Valerie Smith
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Louise C Kenny
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course Science, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Declan Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Maria Noonan
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
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Smith V, Cithambaram K, O'Malley D. Early warning systems in maternity care: protocol for a qualitative evidence synthesis of maternity care providers' views and experiences. HRB Open Res 2021; 4:59. [PMID: 35079691 PMCID: PMC8733824 DOI: 10.12688/hrbopenres.13270.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 01/04/2023] Open
Abstract
Background: Early warning systems (EWS) have been widely adopted for use in maternity settings internationally. The idea in using these systems is early recognition of potential or actual clinical deterioration in pregnant or postpartum women, and escalation of care. Barriers to successful implementation and use of EWS, however, have been identified. If EWS are to be applied consistently, a greater understanding of the views and experiences of EWS from the perspectives of those using and applying EWS in maternity practice is needed. This protocol describes a qualitative evidence synthesis of maternity care providers' (midwives, obstetricians, and allied maternity care professionals) views and experiences of EWS use and application in practice. Methods: Studies will be included in the review if they report on maternity care providers use and application of EWS in any birth setting. Qualitative studies and studies of mixed methods design, where qualitative data can be extracted separately, will be included. To source relevant literature the electronic databases of MEDLINE, CINHAL, Web of Science Core Collection (incorporating Social Science Citation Index) and Maternity and Infant Care (MIDIRS), from date of inception, will be searched. The methodological quality of the included studies will be appraised using the 12-criteria of the assessment tool developed by the Evidence for Policy and Practice Information and Co-ordinating Centre. Thematic synthesis will be used for synthesising the qualitative data from included studies. The confidence in the findings will be assessed using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research. Conclusions: The findings of this qualitative evidence synthesis may provide valuable information on the barriers, challenges, and facilitators for EWS use based on the experiences of those directly involved in EWS application in maternity care provision. PROSPERO registration: CRD42021235137 (08/04/2021).
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Affiliation(s)
- Valerie Smith
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, D02, Ireland
| | | | - Deirdre O'Malley
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, D02, Ireland
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14
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Al-Kalbani M, Lapinsky SE. Pregnancy and Risk. Crit Care Med 2021; 48:765-766. [PMID: 32301773 DOI: 10.1097/ccm.0000000000004262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Moza Al-Kalbani
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada Mount Sinai Hospital; and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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15
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Mbakwem AC, Bauersachs J, Viljoen C, Hoevelmann J, van der Meer P, Petrie MC, Mebazaa A, Goland S, Karaye K, Laroche C, Sliwa K. Electrocardiographic features and their echocardiographic correlates in peripartum cardiomyopathy: results from the ESC EORP PPCM registry. ESC Heart Fail 2021; 8:879-889. [PMID: 33453082 PMCID: PMC8006717 DOI: 10.1002/ehf2.13172] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 11/06/2020] [Accepted: 12/03/2020] [Indexed: 12/17/2022] Open
Abstract
AIMS In peripartum cardiomyopathy (PPCM), electrocardiography (ECG) and its relationship to echocardiography have not yet been investigated in large multi-centre and multi-ethnic studies. We aimed to identify ECG abnormalities associated with PPCM, including regional and ethnic differences, and their correlation with echocardiographic features. METHODS AND RESULTS We studied 411 patients from the EURObservational PPCM registry. Baseline demographic, clinical, and echocardiographic data were collected. ECGs were analysed for rate, rhythm, QRS width and morphology, and QTc interval. The median age was 31 [interquartile range (IQR) 26-35] years. The ECG was abnormal in > 95% of PPCM patients. Sinus tachycardia (heart rate > 100 b.p.m.) was common (51%), but atrial fibrillation was rare (2.27%). Median QRS width was 82 ms [IQR 80-97]. Left bundle branch block (LBBB) was reported in 9.30%. Left ventricular (LV) hypertrophy (LVH), as per ECG criteria, was more prevalent amongst Africans (59.62%) and Asians (23.17%) than Caucasians (7.63%, P < 0.001) but did not correlate with LVH on echocardiography. Median LV end-diastolic diameter (LVEDD) was 60 mm [IQR 55-65] and LV ejection fraction (LVEF) 32.5% [IQR 25-39], with no significant regional or ethnic differences. Sinus tachycardia was associated with an LVEF < 35% (OR 1.85 [95% CI 1.20-2.85], P = 0.006). ECG features that predicted an LVEDD > 55 mm included a QRS complex > 120 ms (OR 11.32 [95% CI 1.52-84.84], P = 0.018), LBBB (OR 4.35 [95% CI 1.30-14.53], P = 0.017), and LVH (OR 2.03 [95% CI 1.13-3.64], P = 0.017). CONCLUSIONS PPCM patients often have ECG abnormalities. Sinus tachycardia predicted poor systolic function, whereas wide QRS, LBBB, and LVH were associated with LV dilatation.
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Affiliation(s)
- Amam C Mbakwem
- Department of Medicine, College of Medicine, University of Lagos, Idi Araba, Lagos, Nigeria
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Charle Viljoen
- Division of Cardiology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Julian Hoevelmann
- Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University Hospital, Homburg/Saar, Germany
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mark C Petrie
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alexandre Mebazaa
- UMR 942 Inserm - MASCOT; University of Paris; Department of Anesthesia-Burn-Critical Care, APHP Saint Louis Lariboisière University Hospitals, Paris, France
| | - Sorel Goland
- Department of Cardiology, Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Kamilu Karaye
- Department of Cardiology, Bayero University, Kano, Nigeria
| | - Cécile Laroche
- ESC, EURObservational Research Programme, Sophia-Antipolis, France
| | - Karen Sliwa
- Division of Cardiology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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16
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Rajbanshi S, Norhayati MN, Nik Hazlina NH. High-risk pregnancies and their association with severe maternal morbidity in Nepal: A prospective cohort study. PLoS One 2020; 15:e0244072. [PMID: 33370361 PMCID: PMC7769286 DOI: 10.1371/journal.pone.0244072] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/02/2020] [Indexed: 12/19/2022] Open
Abstract
Background The early identification of pregnant women at risk of developing complications at birth is fundamental to antenatal care and an important strategy in preventing maternal death. This study aimed to determine the prevalence of high-risk pregnancies and explore the association between risk stratification and severe maternal morbidity. Methods This hospital-based prospective cohort study included 346 pregnant women between 28–32 gestational weeks who were followed up after childbirth at Koshi Hospital in Nepal. The Malaysian antenatal risk stratification approach, which applies four color codes, was used: red and yellow denote high-risk women, while green and white indicate low-risk women based on maternal past and present medical and obstetric risk factors. The World Health Organization criteria were used to identify women with severe maternal morbidity. Multivariate confirmatory logistic regression analysis was performed to adjust for possible confounders (age and mode of birth) and explore the association between risk stratification and severe maternal morbidity. Results The prevalence of high-risk pregnancies was 14.4%. Based on the color-coded risk stratification, 7.5% of the women were categorized red, 6.9% yellow, 72.0% green, and 13.6% white. The women with high-risk pregnancies were 4.2 times more likely to develop severe maternal morbidity conditions during childbirth. Conclusions Although smaller in percentage, the chances of severe maternal morbidity among high-risk pregnancies were higher than those of low-risk pregnancies. This risk scoring approach shows the potential to predict severe maternal morbidity if routine screening is implemented at antenatal care services. Notwithstanding, unpredictable severe maternal morbidity events also occur among low-risk pregnant women, thus all pregnant women require vigilance and quality obstetrics care but high-risk pregnant women require specialized care and referral.
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Affiliation(s)
- Sushma Rajbanshi
- Women’s Health Development Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Mohd Noor Norhayati
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- * E-mail:
| | - Nik Hussain Nik Hazlina
- Women’s Health Development Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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Atkin C, Prinja P, Banerjee A, Holland M, Lasserson D. Provision of acute medicine services for pregnant women in UK hospitals: Data from the Society for Acute Medicine Benchmarking Audit 2019. Obstet Med 2020; 14:83-88. [PMID: 34394716 PMCID: PMC8358240 DOI: 10.1177/1753495x20929502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/19/2020] [Accepted: 04/29/2020] [Indexed: 11/22/2022] Open
Abstract
Background Medical problems during pregnancy are the leading cause of maternal mortality in the UK. Pregnant women often present through acute services to the medical team, requiring timely access to appropriate services, physicians trained to manage medical problems in pregnancy, with locally agreed guidance available. Methods Data were collected through the Society for Acute Medicine Benchmarking Audit, a national audit of service delivery and patient care in acute medicine over a 24 hour period. Results One hundred and thirty hospitals participated: 5.5% had an acute medicine consultant trained in obstetric medicine, and 38% of hospitals had a named lead for maternal medicine. This was not related to hospital size (p = 0.313). Sixty-four units had local guidelines for medical problems in pregnancy; 43% had a local guideline for venous thromboembolism in pregnancy. Centres with a named lead had more guidelines (p = 0.019). Conclusion Current provision of services within acute medicine for pregnant women does not meet national recommendations.
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Affiliation(s)
- Catherine Atkin
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | | | | | | | - Dan Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Department of Acute Medicine, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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18
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Edwards W, Dore S, van Schalkwyk J, Armson BA. Prioritizing Maternal Sepsis: National Adoption of an Obstetric Early Warning System to Prevent Morbidity and Mortality. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:640-643. [PMID: 32171506 DOI: 10.1016/j.jogc.2019.11.072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/21/2019] [Indexed: 01/12/2023]
Abstract
Sepsis is one of the leading causes of maternal morbidity and mortality. Analyses have determined that delays in early recognition and prompt initiation of appropriate management are key contributing factors in maternal sepsis deaths. Recent cases of sepsis-related maternal morbidity and mortality across Canada have highlighted the urgent need for a national standardized approach to the detection and treatment of maternal sepsis. The SOGC has established a national multidisciplinary maternal sepsis task force to address this priority. The adoption of a national modified obstetric early warning system (MEOWS) is recommended as a key first step. This early warning scoring (EWS) system will facilitate early detection of maternal clinical deterioration and mandate timely escalation of care appropriate for the severity of illness. There is currently limited use of EWSs in Canada. Introducing a national EWS and a standardized maternal sepsis management guideline provides a tremendous opportunity to improve maternal care. A standardized approach will facilitate future evidence-based evaluation and refinement of the tool, and enable the reduction of preventable maternal morbidity and mortality from sepsis, as well as all causes duplicated.
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Affiliation(s)
- Wesley Edwards
- Department of Anesthesia and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON.
| | - Sharon Dore
- Department of Obstetrics and Gynaecology, McMaster University, Hamilton, ON
| | - Julie van Schalkwyk
- Department of Obstetrics and Gynaecology, BC Women's Hospital, University of British Columbia, Vancouver, BC
| | - B Anthony Armson
- Department of Obstetrics and Gynaecology, IWK Health Centre, Dalhousie University, Halifax, NS
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Gat R, Hadar E, Orbach-Zinger S, Shochat T, Kushnir S, Einav S. Distribution of Extreme Vital Signs and Complete Blood Count Values of Healthy Parturients: A Retrospective Database Analysis and Review of the Literature. Anesth Analg 2019; 129:1595-1606. [PMID: 31743180 DOI: 10.1213/ane.0000000000003866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The impact of physiological adjustments throughout pregnancy on maternal vital signs and laboratory values has yet to be fully defined. The present study was designed to determine the normal range of these parameters among healthy pregnant women during the peripartum period. METHODS This is a retrospective analysis of data collected during real-time deliveries in a single medical center. Vital signs and laboratory results from the 24 hours preceding delivery room admission and up to 72 hours postpartum were collected. Only pregnant women at term (37 to 41 weeks' gestation) with a liveborn, singleton gestation, and no chronic disease or obstetric complication that could affect the physiological parameters under study were included. The mean, range, and standard deviations of the extremes of all parameters at 3 distinct time points (prelabor, intrapartum, and postpartum) were calculated. The 2.5 and 97.5 percentiles for each parameter were reported as the normal range. RESULTS A total of 32,161 cases fulfilled inclusion criteria. The average gestational age at delivery was 39 weeks ± 8 days, and one-third of the cases were primiparous. During labor and after delivery, the upper limits of normal blood pressure values were 147/94 and 145/94 mm Hg, respectively. The lower limits were 83/43 and 83/42 mm Hg, respectively. Normal heart rates were 60-115 beats/min prelabor, 51-120 beats/min intrapartum, and 50-120 beats/min postpartum. Lowest normal temperatures ranged between 36.0°C and 36.3°C in the 3 study time points, and highest normal temperatures were 37.2°C prelabor and 37.6°C intra- and postpartum. The normal ranges of white blood cell counts were 6.1-16.8 prelabor, 6.5-22.5 intrapartum, and 6.4-23.9 K/µL postpartum. Normal low values of hemoglobin were 9.7, 8.7, and 7.1 g/dL and of platelets were 117, 113, and 105 K/µL, respectively. CONCLUSIONS Our findings justify the practice of using ≥2 repeated measurements for diagnosing hypertensive disorders of pregnancy. Lower normal blood pressure limits may be below those defining hypotensive shock. Normal heart rates exceed the accepted definitions of both tachy- and bradycardia. Normal temperatures at all times have a more narrow range than previously thought, and the normal range of white blood cell count has outliers exceeding the current definitions of leukocytosis or leukopenia at all times. The normal lower range of hemoglobin was constantly below 10 g/dL, and normal platelet counts were considerably lower than those previously described. The vital signs and complete blood count values thus far considered normal for the peripartum period may require some adjustment. New definitions for hypotension, tachy- and bradycardia, fever, and leukocyte quantitative disorders should be considered.
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Affiliation(s)
- Roi Gat
- From the Helen Schneider's Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Hadar
- From the Helen Schneider's Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Tzippy Shochat
- Research Department, Rabin Medical Center, Petach-Tikva, Israel
| | - Shiri Kushnir
- Research Department, Rabin Medical Center, Petach-Tikva, Israel
| | - Sharon Einav
- Surgical Intensive Care Department, Shaare Zedek Medical Center, Jerusalem, Israel
- Hebrew University Faculty of Medicine, Jerusalem, Israel
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20
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Abstract
The quality of maternal care in the United States is receiving increased attention due to rising rates of severe maternal morbidity and maternal mortality when compared with other developed countries. Many of these events are considered preventable. The lack of adoption of evidence-based maternal patient safety bundles and tool kits requires immediate attention. Maternal levels of care described by the American Congress of Obstetricians and Gynecologists requires increased focus so that women are in the appropriate facility to receive care. Perinatal care management, integrated behavioral health, and preconception care should be considered a preferred methodology to achieve optimal maternal outcomes.
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Umar A, Ameh CA, Muriithi F, Mathai M. Early warning systems in obstetrics: A systematic literature review. PLoS One 2019; 14:e0217864. [PMID: 31150513 PMCID: PMC6544303 DOI: 10.1371/journal.pone.0217864] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 05/20/2019] [Indexed: 11/22/2022] Open
Abstract
Introduction Several versions of Early Warning Systems (EWS) are used in obstetrics to detect and treat early clinical deterioration to avert morbidity and mortality. EWS can potentially be useful to improve the quality of care and reduce the risk of maternal mortality in resource-limited settings. We conducted a systematic literature review of published obstetric early warning systems, define their predictive accuracy for morbidity and mortality, and their effectiveness in triggering corrective actions and improving health outcomes. Methods We systematically searched for primary research articles on obstetric EWS published in peer-reviewed journals between January 1997 and March 2018 in Medline, CINAHL, SCOPUS, Science Direct, and Science Citation Index. We also searched reference lists of relevant articles and websites of professional societies. We included studies that assessed the predictive accuracy of EWS to detect clinical deterioration, or/and their effectiveness in improving clinical outcomes in obstetric inpatients. We excluded studies with a paediatric or non-obstetric adult population. Cross-sectional and qualitative studies were also excluded. We performed a narrative synthesis since the outcomes reported were heterogeneous. Results A total of 381 papers were identified, 17 of which met the inclusion criteria. Eleven of the included studies evaluated the predictive accuracy of EWS for obstetric morbidity and mortality, 5 studies assessed the effectiveness of EWS in improving clinical outcomes, while one study addressed both. Sixteen published EWS versions were reviewed, 14 of which included five basic clinical observations (pulse rate, respiratory rate, temperature, blood pressure, and consciousness level). The obstetric EWS identified had very high median (inter-quartile range) sensitivity—89% (72% to 97%) and specificity—85% (67% to 98%) but low median (inter-quartile range) positive predictive values—41% (25% to 74%) for predicting morbidity or ICU admission. Obstetric EWS had a very high accuracy in predicting death (AUROC >0.80) among critically ill obstetric patients. Obstetric EWS improves the frequency of routine vital sign observation, reduces the interval between the recording of specifically defined abnormal clinical observations and corrective clinical actions, and can potentially reduce the severity of obstetric morbidity. Conclusion Obstetric EWS are effective in predicting severe morbidity (in general obstetric population) and mortality (in critically ill obstetric patients). EWS can contribute to improved quality of care, prevent progressive obstetric morbidity and improve health outcomes. There is limited evidence of the effectiveness of EWS in reducing maternal death across all settings. Clinical parameters in most obstetric EWS versions are routinely collected in resource-limited settings, therefore implementing EWS may be feasible in such settings.
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Affiliation(s)
- Aminu Umar
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Charles A. Ameh
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail:
| | - Francis Muriithi
- Blackpool Teaching Hospitals National Health Service Foundation Trust, Blackpool, United Kingdom
| | - Matthews Mathai
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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22
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Vousden N, Lawley E, Nathan HL, Seed PT, Gidiri MF, Goudar S, Sandall J, Chappell LC, Shennan AH. Effect of a novel vital sign device on maternal mortality and morbidity in low-resource settings: a pragmatic, stepped-wedge, cluster-randomised controlled trial. Lancet Glob Health 2019; 7:e347-e356. [PMID: 30784635 PMCID: PMC6379820 DOI: 10.1016/s2214-109x(18)30526-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/19/2018] [Accepted: 11/07/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND In 2015, an estimated 303 000 women died in pregnancy and childbirth. Obstetric haemorrhage, sepsis, and hypertensive disorders of pregnancy account for more than 50% of maternal deaths worldwide. There are effective treatments for these pregnancy complications, but they require early detection by measurement of vital signs and timely administration to save lives. The primary aim of this trial was to determine whether implementation of the CRADLE Vital Sign Alert and an education package into community and facility maternity care in low-resource settings could reduce a composite of all-cause maternal mortality or major morbidity (eclampsia and hysterectomy). METHODS We did a pragmatic, stepped-wedge, cluster-randomised controlled trial in ten clusters across Africa, India, and Haiti, introducing the device into routine maternity care. Each cluster contained at least one secondary or tertiary hospital and their main referral facilities. Clusters crossed over from existing routine care to the CRADLE intervention in one of nine steps at 2-monthly intervals, with CRADLE devices replacing existing equipment at the randomly allocated timepoint. A computer-generated randomly allocated sequence determined the order in which the clusters received the intervention. Because of the nature of the intervention, this trial was not masked. Data were gathered monthly, with 20 time periods of 1 month. The primary composite outcome was at least one of eclampsia, emergency hysterectomy, and maternal death. This study is registered with the ISRCTN registry, number ISRCTN41244132. FINDINGS Between April 1, 2016, and Nov 30, 2017, among 536 223 deliveries, the primary outcome occurred in 4067 women, with 998 maternal deaths, 2692 eclampsia cases, and 681 hysterectomies. There was an 8% decrease in the primary outcome from 79·4 per 10 000 deliveries pre-intervention to 72·8 per 10 000 deliveries post-intervention (odds ratio [OR] 0·92, 95% CI 0·86-0·97; p=0·0056). After planned adjustments for variation in event rates between and within clusters over time, the unexpected degree of variability meant we were unable to judge the benefit or harms of the intervention (OR 1·22, 95% CI 0·73-2·06; p=0·45). INTERPRETATION There was an absolute 8% reduction in primary outcome during the trial, with no change in resources or staffing, but this reduction could not be directly attributed to the intervention due to variability. We encountered unanticipated methodological challenges with this trial design, which can provide valuable learning for future research and inform the trial design of future international stepped-wedge trials. FUNDING Newton Fund Global Research Programme: UK Medical Research Council; Department of Biotechnology, Ministry of Science & Technology, Government of India; and UK Department of International Development.
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Affiliation(s)
- Nicola Vousden
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
| | - Elodie Lawley
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Hannah L Nathan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Muchabayiwa Francis Gidiri
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Shivaprasad Goudar
- Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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23
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Payne BA, Ryan H, Bone J, Magee LA, Aarvold AB, Mark Ansermino J, Bhutta ZA, Bowen M, Guilherme Cecatti J, Chazotte C, Crozier T, de Pont ACJM, Demirkiran O, Duan T, Kallen M, Ganzevoort W, Geary M, Goffman D, Hutcheon JA, Joseph KS, Lapinsky SE, Lataifeh I, Li J, Liskonova S, Hamel EM, McAuliffe FM, O'Herlihy C, Mol BWJ, Seaward PGR, Tadros R, Togal T, Qureshi R, Vivian Ukah U, Vasquez D, Wallace E, Yong P, Zhou V, Walley KR, von Dadelszen P. Development and internal validation of the multivariable CIPHER (Collaborative Integrated Pregnancy High-dependency Estimate of Risk) clinical risk prediction model. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:278. [PMID: 30373675 PMCID: PMC6206915 DOI: 10.1186/s13054-018-2215-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 10/03/2018] [Indexed: 11/10/2022]
Abstract
Background Intensive care unit (ICU) outcome prediction models, such as Acute Physiology And Chronic Health Evaluation (APACHE), were designed in general critical care populations and their use in obstetric populations is contentious. The aim of the CIPHER (Collaborative Integrated Pregnancy High-dependency Estimate of Risk) study was to develop and internally validate a multivariable prognostic model calibrated specifically for pregnant or recently delivered women admitted for critical care. Methods A retrospective observational cohort was created for this study from 13 tertiary facilities across five high-income and six low- or middle-income countries. Women admitted to an ICU for more than 24 h during pregnancy or less than 6 weeks post-partum from 2000 to 2012 were included in the cohort. A composite primary outcome was defined as maternal death or need for organ support for more than 7 days or acute life-saving intervention. Model development involved selection of candidate predictor variables based on prior evidence of effect, availability across study sites, and use of LASSO (Least Absolute Shrinkage and Selection Operator) model building after multiple imputation using chained equations to address missing data for variable selection. The final model was estimated using multivariable logistic regression. Internal validation was completed using bootstrapping to correct for optimism in model performance measures of discrimination and calibration. Results Overall, 127 out of 769 (16.5%) women experienced an adverse outcome. Predictors included in the final CIPHER model were maternal age, surgery in the preceding 24 h, systolic blood pressure, Glasgow Coma Scale score, serum sodium, serum potassium, activated partial thromboplastin time, arterial blood gas (ABG) pH, serum creatinine, and serum bilirubin. After internal validation, the model maintained excellent discrimination (area under the curve of the receiver operating characteristic (AUROC) 0.82, 95% confidence interval (CI) 0.81 to 0.84) and good calibration (slope of 0.92, 95% CI 0.91 to 0.92 and intercept of −0.11, 95% CI −0.13 to −0.08). Conclusions The CIPHER model has the potential to be a pragmatic risk prediction tool. CIPHER can identify critically ill pregnant women at highest risk for adverse outcomes, inform counseling of patients about risk, and facilitate bench-marking of outcomes between centers by adjusting for baseline risk. Electronic supplementary material The online version of this article (10.1186/s13054-018-2215-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Beth A Payne
- Department of Obstetrics and Gynaecology, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada. .,Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada. .,BC Children's Hospital Research Institute and Women's Health Research Institute, University of British Columbia, V3-336 950 W 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.
| | - Helen Ryan
- Department of Obstetrics and Gynaecology, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada.,BC Children's Hospital Research Institute and Women's Health Research Institute, University of British Columbia, V3-336 950 W 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.,Department of Family Practice, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada
| | - Jeffrey Bone
- Department of Obstetrics and Gynaecology, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada.,BC Children's Hospital Research Institute and Women's Health Research Institute, University of British Columbia, V3-336 950 W 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - Laura A Magee
- Department of Obstetrics and Gynaecology, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada.,BC Children's Hospital Research Institute and Women's Health Research Institute, University of British Columbia, V3-336 950 W 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.,Department of Medicine, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada.,School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, Strand, London, WC2R2LS, UK
| | - Alice B Aarvold
- Department of Medicine, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada
| | - J Mark Ansermino
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada.,BC Children's Hospital Research Institute and Women's Health Research Institute, University of British Columbia, V3-336 950 W 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - Zulfiqar A Bhutta
- Center of Excellence in Women & Child Health, Aga Khan University, Block 2 Clifton, Karachi, Sindh, Pakistan.,Centre for Global Child Health, the Hospital for Sick Children, 555 University Ave, Toronto, M5G 1X8, ON, Canada
| | - Mary Bowen
- Rotunda Hospital, University College Dublin, 1, Parnell Square E, Dublin, Ireland
| | - J Guilherme Cecatti
- Universidade Estadual de Campinas, Cidade Universitaria Zeferino Vaz - Barao Geraldo, Campinas, 13083-970, Sao Paulo, Brazil
| | - Cynthia Chazotte
- Montefiore Medical Center, Columbia University Medical Center, 951 Prospect Ave, Bronx, 10459, NY, USA.,Morgan Stanley Children's Hospital & Sloan Hospital for Mothers, 10032, 3959 Broadway, New York, NY, USA
| | - Tim Crozier
- Department of Obstetrics and Gynaecology, Monash University, Wellington Rd, Clayton, 3800, Victoria, Australia
| | | | - Oktay Demirkiran
- Inonu University, Bulgurlu Mahallesi, Malatya, 44000, Battalgazi, Turkey
| | - Tao Duan
- Shanghai 1st Maternity and Infant Hospital, 200000, 536 Changle Rd, Shanghai, Jingan Qu, China
| | - Marlot Kallen
- Academic Medical Centre, Meibergdreef 9, Amsterdam, 1105, AZ, The Netherlands
| | - Wessel Ganzevoort
- Academic Medical Centre, Meibergdreef 9, Amsterdam, 1105, AZ, The Netherlands
| | - Michael Geary
- Rotunda Hospital, University College Dublin, 1, Parnell Square E, Dublin, Ireland
| | - Dena Goffman
- Montefiore Medical Center, Columbia University Medical Center, 951 Prospect Ave, Bronx, 10459, NY, USA.,Morgan Stanley Children's Hospital & Sloan Hospital for Mothers, 10032, 3959 Broadway, New York, NY, USA
| | - Jennifer A Hutcheon
- Department of Obstetrics and Gynaecology, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada.,BC Children's Hospital Research Institute and Women's Health Research Institute, University of British Columbia, V3-336 950 W 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada.,BC Children's Hospital Research Institute and Women's Health Research Institute, University of British Columbia, V3-336 950 W 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - Stephen E Lapinsky
- Mt Sinai Hospital, University of Toronto, 600 University Ave, Toronto, M5G1X5, ON, Canada
| | - Isam Lataifeh
- King Abdullah University Hospital, Ar Ramtha, 3030, Ramtha, Jordan
| | - Jing Li
- Department of Obstetrics and Gynaecology, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada.,BC Children's Hospital Research Institute and Women's Health Research Institute, University of British Columbia, V3-336 950 W 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - Sarka Liskonova
- Department of Obstetrics and Gynaecology, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada.,BC Children's Hospital Research Institute and Women's Health Research Institute, University of British Columbia, V3-336 950 W 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - Emily M Hamel
- Department of Obstetrics and Gynaecology, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada
| | - Fionnuala M McAuliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Belfield Downs, Dublin, D14YH57, Ireland
| | - Colm O'Herlihy
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Belfield Downs, Dublin, D14YH57, Ireland
| | - Ben W J Mol
- Academic Medical Centre, Meibergdreef 9, Amsterdam, 1105, AZ, The Netherlands.,Department of Paediatrics and Women's Health, University of Adelaide, Adelaide, 5005, SA, Australia
| | - P Gareth R Seaward
- Mt Sinai Hospital, University of Toronto, 600 University Ave, Toronto, M5G1X5, ON, Canada
| | - Ramzy Tadros
- King Abdullah University Hospital, Ar Ramtha, 3030, Ramtha, Jordan
| | - Turkan Togal
- Inonu University, Bulgurlu Mahallesi, Malatya, 44000, Battalgazi, Turkey
| | - Rahat Qureshi
- Center of Excellence in Women & Child Health, Aga Khan University, Block 2 Clifton, Karachi, Sindh, Pakistan
| | - U Vivian Ukah
- Department of Obstetrics and Gynaecology, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada.,BC Children's Hospital Research Institute and Women's Health Research Institute, University of British Columbia, V3-336 950 W 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - Daniela Vasquez
- Hospital Interzonal General de Agudos Gral, Av. 101 Dr Ricardo Balbin, Buenos Aires, 3200, Argentina
| | - Euan Wallace
- Department of Obstetrics and Gynaecology, Monash University, Wellington Rd, Clayton, 3800, Victoria, Australia
| | - Paul Yong
- Department of Obstetrics and Gynaecology, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada.,BC Children's Hospital Research Institute and Women's Health Research Institute, University of British Columbia, V3-336 950 W 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - Vivian Zhou
- Inonu University, Bulgurlu Mahallesi, Malatya, 44000, Battalgazi, Turkey
| | - Keith R Walley
- Department of Medicine, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada.,Centre for Heart Lung Innovation, St Paul's Hospital, 1081 Burrard Street, Vancouver, V6Z1Y6, BC, Canada
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, University of British Columbia, 2329 West Mall, Vancouver, V6T 1Z4, BC, Canada.,BC Children's Hospital Research Institute and Women's Health Research Institute, University of British Columbia, V3-336 950 W 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.,School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, Strand, London, WC2R2LS, UK
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24
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Robbins T, Shennan A, Sandall J. Modified early obstetric warning scores: A promising tool but more evidence and standardization is required. Acta Obstet Gynecol Scand 2018; 98:7-10. [PMID: 30155879 PMCID: PMC7028086 DOI: 10.1111/aogs.13448] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 08/21/2018] [Accepted: 08/22/2018] [Indexed: 11/29/2022]
Abstract
Early warning systems involve the routine monitoring and recording of vital signs or clinical observations on specifically designed charts with linked escalation protocols. Meeting criteria for abnormal physiological parameters triggers a color-coded or weighted scoring system aimed to guide the frequency of monitoring, need for, and urgency of clinical review. Color-coded systems trigger a clinical response when one or more abnormal observation is recorded in the red zone or two or more mildly abnormal parameters in the amber zone. The principle of maternity-specific early warning systems to structure surveillance for hospitalized women is intuitive. The widespread use and policy support, including recommendations following confidential enquiries and from the National Health Service Litigation Authority, is not, however, currently backed up by a strong evidence base. Research is required to develop predictive models and validate evidence-based maternity-specific early warning systems in the general maternity population.
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Affiliation(s)
- Tanya Robbins
- Department of Women and Children's Health, King's College London, London, UK
| | - Andrew Shennan
- Department of Women and Children's Health, King's College London, London, UK
| | - Jane Sandall
- Department of Women and Children's Health, King's College London, London, UK
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25
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Burlinson CEG, Sirounis D, Walley KR, Chau A. Sepsis in pregnancy and the puerperium. Int J Obstet Anesth 2018; 36:96-107. [PMID: 29921485 DOI: 10.1016/j.ijoa.2018.04.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 04/27/2018] [Accepted: 04/30/2018] [Indexed: 12/30/2022]
Abstract
Sepsis remains a leading cause of maternal morbidity and mortality. Recognition and treatment of maternal sepsis are often delayed due to the physiological adaptations of pregnancy and vague or absent signs and symptoms during its initial presentation. Over the past decade, our understanding of sepsis has evolved and maternal early warning systems have been developed in an effort to help providers promptly identify and stratify parturients who are at risk. In addition, new consensus definitions and care bundles have recently been published by the World Health Organization and the Surviving Sepsis Campaign to facilitate earlier recognition and timely management of sepsis. In this narrative review, we summarize the available evidence about sepsis and provide an overview of the research efforts focused on maternal sepsis to date. Controversies and challenges surrounding the anesthetic management of parturients with sepsis or at risk of developing sepsis during pregnancy or the puerperium will be highlighted.
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Affiliation(s)
- C E G Burlinson
- Department of Anesthesia, British Columbia Women's Hospital, Vancouver, BC, Canada
| | - D Sirounis
- Division of Critical Care Medicine, Department of Medicine, St. Paul's Hospital, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - K R Walley
- Division of Critical Care Medicine, Department of Medicine, St. Paul's Hospital, Vancouver, BC, Canada; Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
| | - A Chau
- Department of Anesthesia, British Columbia Women's Hospital, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.
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26
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Following NEWS trend: charting progress in obstetrics? Int J Obstet Anesth 2018; 33:1-3. [DOI: 10.1016/j.ijoa.2017.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 09/21/2017] [Accepted: 09/26/2017] [Indexed: 11/17/2022]
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27
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Smith C, Brown J. Could Pregnant Canadian Women Benefit From an Early Obstetric Warning System? JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:397-398. [PMID: 29306682 DOI: 10.1016/j.jogc.2017.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 10/03/2017] [Indexed: 11/15/2022]
Affiliation(s)
- Catherine Smith
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC
| | - James Brown
- Department of Anesthesiology, BC Women's Hospital, Vancouver, BC
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28
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Kouskouti C, Evangelatos N, Brand A, Kainer F. Maternal sepsis in the era of genomic medicine. Arch Gynecol Obstet 2017; 297:49-60. [PMID: 29103195 DOI: 10.1007/s00404-017-4584-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 10/26/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE Maternal sepsis remains one of the leading causes of direct and indirect maternal mortality both in high- and low-income environments. In the last two decades, systems biology approaches, based on '-omics' technologies, have started revolutionizing the diagnosis and management of the septic syndrome. The scope of this narrative review is to present an overview of the basic '-omics' technologies, exemplified by cases relevant to maternal sepsis. METHODS Narrative review of the new '-omics' technologies based on a detailed review of the literature. RESULTS After presenting the main 'omics' technologies, we discuss their limitations and the need for integrated approaches that encompass research efforts across multiple '-omics' layers in the '-omics' cascade between the genome and the phenome. CONCLUSIONS Systems biology approaches are revolutionizing the research landscape in maternal sepsis. There is a need for increased awareness, from the side of health practitioners, as a requirement for the effective implementation of the new technologies in the research and clinical practice in maternal sepsis.
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Affiliation(s)
- C Kouskouti
- Department of Obstetrics and Perinatal Medicine, Klinik Hallerwiese, St. Johannis-Mühlgasse 19, 90419, Nuremberg, Germany.
| | - N Evangelatos
- Intensive Care Medicine Unit, Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University, Nuremberg, Germany.,UNU-MERIT (Maastricht Economic and Social Research Institute on Innovation and Technology), Maastricht University, Boschstraat 24, 6211 AX, Maastricht, The Netherlands
| | - A Brand
- Public Health Genomics, Department International Health, Maastricht University, Duboisdomain 30, 6229 GT, Maastricht, The Netherlands.,Professorial Fellow, UNU-MERIT (Maastricht Economic and Social Research Institute on Innovation and Technology), Maastricht University, Boschstraat 24, 6211 AX, Maastricht, The Netherlands.,Dr. TMA Pai Endowed Chair Public Health Genomics, Manipal University, Madhav Nagar, Manipal, Karnataka, 576104, India
| | - F Kainer
- Department of Obstetrics and Perinatal Medicine, Klinik Hallerwiese, St. Johannis-Mühlgasse 19, 90419, Nuremberg, Germany
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