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The near-miss maternal morbidity scoring system was tested in a clinical setting in Brazil
Journal of Clinical Epidemiology 58 (2005) 962–966
LETTERS TO THE EDITORS The near-miss maternal morbidity scoring system was tested in a clinical setting in Brazil We congratulate the authors for their development of a scoring system specifically designed for the identification of women with near-miss maternal morbidity and differentiating them from those with other severe but not life-threatening conditions [1]. We suspect and hope that availability of such a score will play an important role in the future. Considering the gold standard adopted (i.e., qualitative clinical assessment based on chart review), we agree with the authors about the importance of applying this scoring system in other clinical settings and therefore adapted it to a previous study (performed between July 1, 2003, and June 30, 2004) that used a severe maternal morbidity database fed by an intrahospital surveillance system. This system operates at a university hospital that serves as a tertiary referral center for a region of 3 million inhabitants. In the 12-month study period, 2,929 women delivered, 2 maternal deaths occurred, and 124 women were classified as having severe morbidity. The criteria for this classification were those proposed by Mantel [2] and Waterstone [3]. According to the five-factor scoring system, there were 20 cases of near-miss and 104 cases of other severe morbidity. Beyond identifying the near-miss cases, we attempted to evaluate the complexity of these cases, comparing the total time of hospital stay and the number of special procedures performed in each group (near-misses vs. other severe morbidities). Included in our consideration were special procedures not usually performed in the obstetric care, such as mechanical ventilation, orotracheal intubation, computerized tomography, or hemodynamic monitoring. The mean number of special procedures performed in the near-miss cases was 3.75 (⫾2.34) per case; in the other severe morbidity cases it was 0.38 (⫾0.83). The mean total time of hospital stay in the near-miss cases was 24.2 days (⫾28.1); in the other severe morbidity cases it was 7.6 days (⫾4.3). For both measures, the difference was significant (P ⬍ .05). If the hospital stay and the requirement for special procedures were considered indicators of management complexity, and if they were considered as the linkage between management complexity and clinical severity, we could conclude that the five-factor scoring system can objectively describe and identify the extremely severe cases of maternal morbidity. Looking at the sensitivity and specificity of the scoring system, as applied across hospitals with highly variable admissions to intensive care units, we suggest that organ dysfunction be clearly defined. Recall that different definitions 0895-4356/05/$ – see front matter
쑖 2005 Elsevier Inc. All rights reserved.
of organic dysfunction exist [2,4], and adopting any one definition can introduce a bias that leads to inadequate recognition of the cases in the continuum of maternal morbidity.
Acknowledgments We thank the authors for considering these issues. Joa˜o Paulo Dias de Souza Jose´ Guilherme Cecatti Department of Obstetrics and Gynecology University of Campinas P.O. Box 6081 13083-881 Campinas – SP, Brazil E-mail address: [email protected] (J.G. Cecatti).
References [1] Geller SE, Rosenberg D, Cox S, Brown M, Simonson L, Kilpatrick S. A scoring system identified near-miss maternal morbidity during pregnancy. J Clin Epidemiol 2004;57:716–20. [2] Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot study of a definition for a near-miss. Br J Obstet Gynaecol 1998;105:985–90. [3] Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case-control study. BMJ 2001;322:1089–93; discussion 1093–4. [4] Vincent JL, Moreno R, Takala J, Willatts S, De Mendonc¸a A, Bruining H, Reinhart CK, Suter PM, Thijs LG; on behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med 1996;22: 707–10. doi:10.1016/j.jclinepi.2005.02.011
Author’s response to: The near-miss maternal morbidity scoring system was tested in a clinical setting in Brazil We were pleased to see the letter to the editors from Joa˜o Paulo Dias de Souza and Jose´ Guilherme Cecatti [1], regarding application of our scoring system [2] to their sample of maternal morbidities in Brazil. Their reported findings using our five-factor scoring system to define their sample of 124 women with maternal morbidity are consistent with our results. They classified 20 cases of near-miss morbidity (16%) and 104 cases of severe morbidity (84%), and
LETTERS TO THE EDITORS The near-miss maternal morbidity scoring system was tested in a clinical setting in Brazil We congratulate the authors for their development of a scoring system specifically designed for the identification of women with near-miss maternal morbidity and differentiating them from those with other severe but not life-threatening conditions [1]. We suspect and hope that availability of such a score will play an important role in the future. Considering the gold standard adopted (i.e., qualitative clinical assessment based on chart review), we agree with the authors about the importance of applying this scoring system in other clinical settings and therefore adapted it to a previous study (performed between July 1, 2003, and June 30, 2004) that used a severe maternal morbidity database fed by an intrahospital surveillance system. This system operates at a university hospital that serves as a tertiary referral center for a region of 3 million inhabitants. In the 12-month study period, 2,929 women delivered, 2 maternal deaths occurred, and 124 women were classified as having severe morbidity. The criteria for this classification were those proposed by Mantel [2] and Waterstone [3]. According to the five-factor scoring system, there were 20 cases of near-miss and 104 cases of other severe morbidity. Beyond identifying the near-miss cases, we attempted to evaluate the complexity of these cases, comparing the total time of hospital stay and the number of special procedures performed in each group (near-misses vs. other severe morbidities). Included in our consideration were special procedures not usually performed in the obstetric care, such as mechanical ventilation, orotracheal intubation, computerized tomography, or hemodynamic monitoring. The mean number of special procedures performed in the near-miss cases was 3.75 (⫾2.34) per case; in the other severe morbidity cases it was 0.38 (⫾0.83). The mean total time of hospital stay in the near-miss cases was 24.2 days (⫾28.1); in the other severe morbidity cases it was 7.6 days (⫾4.3). For both measures, the difference was significant (P ⬍ .05). If the hospital stay and the requirement for special procedures were considered indicators of management complexity, and if they were considered as the linkage between management complexity and clinical severity, we could conclude that the five-factor scoring system can objectively describe and identify the extremely severe cases of maternal morbidity. Looking at the sensitivity and specificity of the scoring system, as applied across hospitals with highly variable admissions to intensive care units, we suggest that organ dysfunction be clearly defined. Recall that different definitions 0895-4356/05/$ – see front matter
쑖 2005 Elsevier Inc. All rights reserved.
of organic dysfunction exist [2,4], and adopting any one definition can introduce a bias that leads to inadequate recognition of the cases in the continuum of maternal morbidity.
Acknowledgments We thank the authors for considering these issues. Joa˜o Paulo Dias de Souza Jose´ Guilherme Cecatti Department of Obstetrics and Gynecology University of Campinas P.O. Box 6081 13083-881 Campinas – SP, Brazil E-mail address: [email protected] (J.G. Cecatti).
References [1] Geller SE, Rosenberg D, Cox S, Brown M, Simonson L, Kilpatrick S. A scoring system identified near-miss maternal morbidity during pregnancy. J Clin Epidemiol 2004;57:716–20. [2] Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot study of a definition for a near-miss. Br J Obstet Gynaecol 1998;105:985–90. [3] Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case-control study. BMJ 2001;322:1089–93; discussion 1093–4. [4] Vincent JL, Moreno R, Takala J, Willatts S, De Mendonc¸a A, Bruining H, Reinhart CK, Suter PM, Thijs LG; on behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med 1996;22: 707–10. doi:10.1016/j.jclinepi.2005.02.011
Author’s response to: The near-miss maternal morbidity scoring system was tested in a clinical setting in Brazil We were pleased to see the letter to the editors from Joa˜o Paulo Dias de Souza and Jose´ Guilherme Cecatti [1], regarding application of our scoring system [2] to their sample of maternal morbidities in Brazil. Their reported findings using our five-factor scoring system to define their sample of 124 women with maternal morbidity are consistent with our results. They classified 20 cases of near-miss morbidity (16%) and 104 cases of severe morbidity (84%), and