RESUMO
OBJECTIVES: We aimed to establish new cut-off values for SIRS (Systemic Inflammatory Response Syndrome) variables in the obstetric population. METHODS: A prospective cohort study in pregnant and postpartum women admitted with systemic infections between December 2017 and January 2019. Patients were divided into three cohorts: Group A, patients with infection but without severe maternal outcomes (SMO); Group B, patients with infection and SMO or admission to the intensive care unit (ICU); and Group C, a control group. Outcome measures were ICU admission and SMO. The relationship between SIRS criteria and SMO was expressed as the area under the receiver operating characteristics curve (AUROC), selecting the best cut-off for each SIRS criterion. RESULTS: A total of 541 obstetric patients were enrolled, including 341 with infections and 200 enrolled as the reference group (Group C). The patients with infections included 313 (91.7%) in Group A and 28 (8.2%) in Group B. There were significant differences for all SIRS variables in Group B, compared with Groups A and C, but there were no significant differences between Groups A and C. The best cut-off values were the following: temperature 38.2 °C, OR 4.1 (1.8-9.0); heart rate 120 bpm, OR 2.9 (1.2-7.4); respiratory rate 22 bpm, OR 4.1 (1.6-10.1); and leukocyte count 16,100 per mcl, OR 3.5 (1.6-7.6). CONCLUSIONS: The cut-off values for SIRS variables did not differ between healthy and infected obstetric patients. However, a higher cut-off may help predict the population with a higher risk of severe maternal outcomes.
Assuntos
Infecções , Complicações do Trabalho de Parto , Infecção Puerperal , Risco Ajustado/métodos , Síndrome de Resposta Inflamatória Sistêmica , Adulto , Estudos de Coortes , Colômbia/epidemiologia , Diagnóstico Precoce , Feminino , Humanos , Infecções/complicações , Infecções/diagnóstico , Infecções/epidemiologia , Infecções/fisiopatologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Contagem de Leucócitos/métodos , Mortalidade Materna , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/etiologia , Complicações do Trabalho de Parto/mortalidade , Gravidez , Resultado da Gravidez/epidemiologia , Infecção Puerperal/sangue , Infecção Puerperal/etiologia , Infecção Puerperal/mortalidade , Infecção Puerperal/terapia , Medição de Risco/métodos , Avaliação de Sintomas/métodos , Síndrome de Resposta Inflamatória Sistêmica/sangue , Síndrome de Resposta Inflamatória Sistêmica/epidemiologia , Síndrome de Resposta Inflamatória Sistêmica/etiologia , Síndrome de Resposta Inflamatória Sistêmica/terapiaRESUMO
BACKGROUND: Every day, about 830 women die worldwide from preventable causes related to pregnancy and childbirth. Obstetric early warning scores have been proposed as a potential tool to reduce maternal morbidity and mortality, based on the identification of predetermined abnormal values in the vital signs or laboratory parameters, to generate a rapid and effective medical response. Several early warning scores have been developed for obstetrical patients, but the majority are the result of a clinical consensus rather than statistical analyses of clinical outcome measures (ie, maternal deaths). In 2013, the Intensive Care National Audit and Research Center Case Mix Program reported the first statistically validated early warning scoring system for pregnant women. OBJECTIVE: We sought to assess the performance of the Intensive Care National Audit and Research Center Obstetric Early Warning Score in predicting death among pregnant women who required admission to the intensive care unit. STUDY DESIGN: This retrospective cohort study included pregnant women admitted to the intensive care unit at a tertiary referral center from January 2006 through December 2011 in Colombia, a developing country, with direct and indirect obstetric-related conditions. The Obstetric Early Warning Score was calculated based on data collected during the first 24 hours of intensive care unit admission. The Obstetric Early Warning Score is calculated based on values of the following variables: systolic and diastolic blood pressure, respiratory rate, heart rate, fraction of inspired oxygen (FiO2) required to maintain an oxygen saturation ≥96%, temperature, and level of consciousness. The performance of the Obstetric Early Warning Score was evaluated using the area under the receiver operator characteristic curve. Outcomes selected were: maternal death, need for mechanical ventilation, and/or vasoactive support. Statistical methods included distribution appropriate univariate analyses and multivariate logistic regression. RESULTS: During the study period, 50,897 births were recorded. There were 724 obstetric admissions to critical care, for an intensive care unit admission rate of 14.22 per 1000 deliveries. A total of 702 women were included in the study, with 29 (4.1%) maternal deaths, and a mortality ratio of 56.98 deaths per 100,000 live births. The most frequent causes of admission were direct, obstetric-related conditions (n = 534; 76.1%). The Obstetric Early Warning Score value was significantly higher in nonsurvivors than in survivors [12 (interquartile range 10-13) vs 7 (interquartile range 4-9); P < .001]. Peripartum women with normal values of Obstetric Early Warning Score had 0% mortality rate, while those with high Obstetric Early Warning Score values (>6) had a mortality rate of 6.3%. The area under the receiver operator characteristic curve of the Obstetric Early Warning Score in discrimination of maternal death was 0.84 (95% confidence interval, 0.75-0.92). The overall predictive value of the Obstetric Early Warning Score was better when the main cause of admission was directly related to pregnancy or the postpartum state. The area under the receiver operator characteristic curve of the score in conditions directly related to pregnancy and postpartum was 0.87 (95% confidence interval, 0.79-0.95), while in indirectly related conditions the area under the receiver operator characteristic curve was 0.77 (95% confidence interval, 0.58-0.96). CONCLUSION: Although there are opportunities for improvement, Obstetric Early Warning Score obtained upon admission to the intensive care unit can predict survival in conditions directly related to pregnancy and postpartum. The use of early warning scores in obstetrics may be a highly useful approach in the early identification of women at an increased risk of dying.
Assuntos
Pressão Sanguínea , Temperatura Corporal , Transtornos da Consciência/epidemiologia , Estado Terminal/mortalidade , Frequência Cardíaca , Morte Materna/estatística & dados numéricos , Oxigenoterapia , Taxa Respiratória , Adulto , Estudos de Coortes , Colômbia , Estado de Consciência , Cuidados Críticos , Estado Terminal/terapia , Feminino , Humanos , Unidades de Terapia Intensiva , Modelos Logísticos , Análise Multivariada , Período Periparto , Gravidez , Curva ROC , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco , Vasoconstritores/uso terapêutico , Adulto JovemRESUMO
PURPOSE: To estimate the mortality rate and trends of respiratory failure in the pregnant and postpartum population of Colombia. METHODS: A retrospective analysis of the national registry of mortality in Colombia was performed from 1998 to 2009. Maternal death was defined as death that occurred during pregnancy or up to 42 days postpartum. Two independent investigators reviewed maternal deaths to determine deaths caused by respiratory failure. Inter-rater agreement was assessed by kappa correlation coefficient. Causes of respiratory failure were identified according to the International Classification of Diseases (ICD-10). RESULTS: During the study period, 8,637,486 live births were reported with 6,676 maternal deaths for an overall maternal mortality rate (MMR) of 82.9 per 100,000 live births. Of these, a total of 835 cases were related to respiratory failure, with a specific MMR of 9.69 per 100,000 live births. The main causes of maternal deaths due to respiratory failure included pulmonary sepsis (284 cases, or 3.58 per 100,000 live births), pulmonary embolism (119 cases or 1.50 per 100,000 live births), and preeclampsia-related pulmonary edema (112 cases or 1.41 per 100,000 live births). All-cause maternal mortality ratio decreased yearly from 1998 to 2009 by -3.76% (95% CI -4.83 to -2.67), while the trend of mortality secondary to respiratory failure remained stable over time (P = 0.449). CONCLUSIONS: Respiratory failure is an important cause of mortality in the obstetric population in Colombia, with pulmonary sepsis as the lead cause of respiratory failure among maternal deaths. While overall maternal mortality rates have decreased in the last decade, respiratory failure-related deaths have remained stable over time.