Eclampsia reduction with maternal early warning trigger tool

OBJECTIVES

To observe the incidence of eclampsia before and after implementing Maternal Early Warning Trigger (MEWT) tool.

STUDY DESIGN

A retrospective observational study to evaluate the effect of introduction of MEWT tool in a tertiary referral center with 10,000 annual births. Two epochs of five years duration were compared before and after implementing MEWT tool. MEWT tool has triggers for early identification of clinical deterioration and pathways for four most important maternal morbidity causes including hypertension. Hypertension pathway has emphasis on rapid control of severe acute hypertension, lab tests and magnesium sulfate prophylaxis. All pregnant women who registered and delivered at the study institute were included.

MAIN OUTCOMES MEASURES

Primary outcome was effect of MEWT tool on the incidence of eclampsia. A subset analysis was done to study the effect of MEWT tool on maternal and perinatal outcomes in women with hypertensive disease. Maternal ICU admissions, HELLP, pulmonary oedema, intracranial bleed and maternal deaths, and perinatal mean birthweight and gestational age, NICU admissions, prematurity, stillbirths, and neonatal deaths were compared.

RESULTS

The study period had 37,043 and 45,637 women in pre- and post-MEWT periods. The incidence of eclampsia reduced by 45.4 % from 1.1 to 0.6 per 1000 women (p 0.001). The most significant reduction was seen with antepartum eclampsia (0.8 to 0.3 per 1000, p = 0.02). There was significant reduction in all maternal and perinatal outcomes in women with hypertensive disorders (3,506 and 6,016 in pre- and post- MEWT periods) after introduction of MEWT tool.

CONCLUSION

Integrating the MEWT tool into the obstetric practice helps in reducing the incidence of eclampsia and improving maternal and fetal outcomes.

Need for guidelines for the combined management of pregnancy and dengue: a retrospective study from an Indian tertiary care maternity hospital

The incidence of dengue has risen in India in recent years. Evidence suggests that dengue in pregnancy may be associated with adverse maternal and fetal outcomes. The aim of our study was to analyse outcomes in pregnant women with confirmed dengue infection who had the benefit of close monitoring and intensive management at a tertiary maternity facility. We reviewed hospital data of 44 (0.11%) such women at Fernandez Hospital, a tertiary maternity unit, during the five-year period from 2011 to 2016. Maternal and fetal variables were collected from case sheets. Dengue haemorrhagic fever was seen in 15.9% and dengue shock syndrome in one fatal case (2.2%). Thrombocytopenia was seen in 31 cases (70.4%) and 14 (31.81%) received platelets transfusions. Fetal outcomes in our series were favourable, except for one stillbirth, with 45.4% preterm deliveries and 15.9% small for gestational age babies. Dengue in pregnancy is definitely associated with maternal and fetal morbidity and mortality. A high index of suspicion of dengue is required in pregnant women with pyrexia and thrombocytopenia.

Implications of the revised consensus body mass indices for asian indians on clinical obstetric practice

BACKGROUND

The body mass index (BMI) categories for Asian Indians has been revised based on consensus guidelines. The revised guidelines categorize overweight as a BMI of 23.0 - 24.9 and obesity as a BMI≥25.

AIM

To determine the change in prevalence of overweight and obese pregnant women, and maternal and fetal associations with overweight and obese pregnant women classified using the revised consensus guidelines for BMI in Asian Indians.

MATERIALS AND METHODS

A retrospective analysis of case records of pregnant women between January 2010 and December 2012 at a tertiary care institute in India. BMI was classified using the revised consensus guidelines for Asian Indians and the World Health Organization (WHO) criteria. The strength and direction of associations with maternal and fetal outcomes was explored with a multivariate regression model.

RESULTS

The prevalence of obesity increased from 11.81% with the WHO criteria to 43.11% with the revised consensus guidelines and led to the re-classification of 1,345 (18.47%) pregnant women from a low risk category to a high risk category.Gestational hypertension, gestational diabetes and large for gestational age babies was associated with overweight or obesity (both Indian and WHO guidelines). Obesity (both Indian and WHO guidelines) was also significantly associated with caesarean sections (adjusted OR 1.23 and 1.51 respectively).

CONCLUSION

The use of the revised guidelines led to a larger classification of high risk Asian Indian pregnant women. Retention of adverse associations of overweight and obesity support adoption of the revised guidelines in obstetric management of Asian Indians.

Organ dysfunction and organ failure as predictors of outcomes of severe maternal morbidity in an obstetric intensive care unit

BACKGROUND

Most of the maternal deaths are preceded by severe maternal morbidity (SMM). Organ dysfunction and organ failure may occur as part of the pathophysiologic spectrum in SMM.

AIM

To determine the predictive and discriminative abilities of the Sequential Organ Failure Assessment (SOFA) scores to determine outcomes in pregnant women with SMM, who were admitted to a maternal ICU.

MATERIALS AND METHODS

A retrospective study design was used to ascertain the diagnostic effectiveness of Sequential Organ Failure Assessment (SOFA) scores. Maximum individual SOFA scores and total maximum SOFA score were compared between women with and without SMM, and in women with SMM who survived or did not survive. Primary outcome measure of interest was maternal mortality.

RESULTS

A majority (n=73, 85.88%) of the 85 women in the study had obstetrics related causes. The total maximum SOFA score was significantly higher in women with SMM as compared to that in women without SMM (p<0.001). The total maximum SOFA score showed ability to discriminate pregnant women with SMM who would not survive (AUROC 0.77, 95% CI: 0.46, 1.00). The positive likelihood ratios and accuracy for total SOFA scores of ≥10 and ≥12 were 19.20 and 38.40, and 94.20% and 95.65% respectively. The post-test probabilities for maternal deaths in women with SMM for SOFA scores ≥10 and ≥12 were 60.01% and 75.01% respectively.

CONCLUSION

The total maximum SOFA score showed good predictive and discriminative abilities for maternal mortality in pregnant women with SMM, who were admitted to ICU.