Prediction of Maternal Morbidity and Mortality Risk Among Women with Medical Disorders Presenting to Emergency Obstetric care (EMOC): A Prospective Observational Study

Abstracts

Introduction

Medical disorders complicating pregnancy have recently emerged as the most common cause for maternal morbidity and mortality and it is important to predict mortality risk when they present in moribund state to emergency obstetric care so as to take and timely effective measures to prevent mortality.

Methods

This prospective observational study was conducted over 6 months among pregnant and post-partum women with medical disorders who sought emergency obstetric care at a tertiary care hospital. Severity of morbidity was assessed using SOFA and APACHE II scores at admission.

Results

Of the 128 women, 87.5% were pregnant, and 12.5% were post-partum. Hypertensive disorders, cardiac disorders, neurological disorders and infective disorders were 24.2%, 22.6%, 14% and 9.4%, respectively. The optimal cut-off SOFA score was 2 (AUC = 0.739) with 66% sensitivity and 71% specificity and APACHE II score cut-off was 6 (AUC = 0.732) with a sensitivity of 60% and specificity of 78% in predicting severe maternal morbidity. The median scores of APACHE II and SOFA are 14 and 4, respectively, for non-survivors and for survivors it was 4 and 1.

Conclusion

Hypertensive disorder was the most common medical disorder, but severity was high in cardiac disorder. SOFA and APACHE II scores are good predictors of morbidity and mortality risk.

Appendix 1

Calculation of apache II score: value range from 0 to 71.

APACHE II Score = Acute physiology score (A) + Glasgow coma score (B) + Chronic health points (C).

A. Acute physiology score

Acute physiology score					Normal range
Score	4	3	2	1	0	1	2	3	4
Rectal temperature (°C)	≥ 41	39–40.9	–	38.5–38.9	36–38.4	34–35.9	32–33.9	30–31.9	≤ 29.9
Mean blood pressure (mmHg)	≥ 160	130–159	110–129	–	70–109	–	50–69	–	≤ 49
Heart rate	≥ 180	140–179	110–139	–	70–109	–	55–69	45–54	≤ 39
Respiratory rate	≥ 50	35–49	–	25–34	12–24	10–11	6–9	–	≤ 5
Arterial pH	≥ 7.7	7.6–7.69	–	7.5 –7.59	7.33–7.49	–	7.25–7.32	7.15–7.24	≤ 7.15
Oxygenation, PaO2	≥ 500	350–499	200–349	–	< 200 > 70	61–70	–	55–60	< 55
Serum sodium (mEq/L)	≥ 180	160–179	155–159	150–154	130–149	–	120–129	111–119	≤ 110
Serum potassium (mEq/L)	≥ 7	6–6.9	–	5.5–5.9	3.5–5.4	3–3.4	2.5–2.9	–	< 2.5
Serum creatinine (mg/dL)	≥ 3.5	2–3.4	1.5–1.9	–	0.6–1.4	–	< 0.6	–	–
Haematocrit (%)	≥ 60	–	50–59.9	46–49.9	30–45.9	–	20–29.9	–	< 20
WBC count (103/ml)	≥ 40	–	20–39.9	15–19.9	3–14.9	–	1–2.9	–	< 1

B. Glasgow coma scale

Eye opening	Verbal non-intubated	Verbal intubated	Motor activity
4 = spontaneous	5—Oriented and talks	5—Seems able to talk	6—Verbal command
3 = verbal stimuli	4—Disoriented and talks	3—Questionable ability to talk	5—Localizes to pain
2 = painful stimuli	3—Inappropriate words	1—Generally unresponsive	4—Withdraws from pain
1 = no response	2—Incomprehensible sounds		3—Decorticate
	1—No response		2—Decerebrate
			1—No response

C. Chronic health points

History of chronic condition	Score
None	0
If elective post-operative patient with immunocompromise or severe organ insufficiency	2
Non-operative patient or emergency post-operative patient with immunocompromise or severe organ insufficiency	5

D. Calculation of SOFA score: value range from 0 to 24

System	Scores
	0	1	2	3	4
Respiratory system parameter, PaO2/FiO2 (mmHg)	≥ 400	< 400	< 300	< 200	< 100
Coagulation system Platelets *103/µL	> 150	< 150	< 100	< 50	< 20
Hepatobiliary system parameter Bilirubin, mg/dL	< 1.2	1.2–1.9	2–5.9	6–11.9	> 12
Cardiovascular parameter	MAP > 70 mmHg	MAP < 70 mmHg	Dopamine < 5 or dobutamine (any dose)	Dopamine 5.1–15 or epinephrine < 0.1 or norepinephrine < 0.1	Dopamine > 15 or Epinephrine > 0.1 or norepinephrine > 0.1
Central nervous system Glasgow coma scale	15	13–14	10–12	6–9	< 6
Renal parameters creatinine, mg/dL	< 1.2	1.2–1.9	2–3.4	3.5–4.9	> 5
Urine output, ml/day				< 500	< 200