Fernandes Figueira Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.
Eur J Obstet Gynecol Reprod Biol. 2013 Mar;167(1):24-8. doi: 10.1016/j.ejogrb.2012.10.030. Epub 2012 Nov 19.
Despite recent guidelines proposed by the World Health Organization (WHO), the operational definition of maternal near-miss (MNM) is still heterogeneous. This study aimed at evaluating the pros and cons of three instruments in characterizing MNM cases. The performance of two of the three instruments was also investigated vis-à-vis the WHO criteria.
A retrospective chart review study was carried out in a tertiary maternity hospital in Rio de Janeiro, Brazil. The medical records of 1163 obstetric hospital admissions from January to December 2008 were reviewed. Cases were first classified as 'positive' or otherwise according to the WHO, Waterstone and literature-based criteria. A descriptive analysis was then carried out focusing on divergent classifications. Finally, diagnostic properties of the Waterstone and the literature-based criteria were calculated taking the WHO criteria as reference standard.
There were eight maternal deaths, 157 cases classified as 'positive' by at least one of the three approaches and 998 cases without severe morbidities. Twenty-seven cases of MNM were detected according to the WHO criteria, whereas the Waterstone and the literature-based criteria identified 123 and 153 cases, respectively. Among the 130 cases identified as 'negative' by the WHO criteria and 'positive' by the Waterstone or literature-based criteria, 119 presented hypertensive disorders (91.5%). Additionally, four cases were identified exclusively by the WHO criteria because of acute thrombocytopenia (platelets<50,000). Estimates of sensitivity, specificity, accuracy and negative predictive values were all above 75% for the Waterstone and literature-based approaches, but both criteria presented positive predictive values (PPV) below 60% even with high magnitudes of MNM.
These results underline that different approaches entail heterogeneous estimates of MNM. The Waterstone and the literature-based criteria are not suitable for a definitive diagnosis of MNM in view of their low PPV, but they seem adequate as a first approach in investigating MNM. While negative results by both alternative criteria virtually rule out MNM, a positive result would require a reassessment using the WHO criteria to confirm the diagnosis of maternal near-miss.
尽管世界卫生组织（WHO）最近提出了指导方针，但孕产妇近死症（MNM）的操作定义仍然存在差异。本研究旨在评估三种工具在描述 MNM 病例方面的优缺点。还研究了这三种工具中的两种与 WHO 标准的关系。
这是一项在巴西里约热内卢的一家三级妇产医院进行的回顾性图表审查研究。对 2008 年 1 月至 12 月期间的 1163 例产科住院患者的病历进行了回顾。根据 WHO、Waterstone 和基于文献的标准，首先将病例分类为“阳性”或“阴性”。然后进行描述性分析，重点关注分类差异。最后，以 WHO 标准为参考标准，计算 Waterstone 和基于文献的标准的诊断特性。
有 8 例产妇死亡，有 157 例病例至少符合三种方法中的一种标准被分类为“阳性”，有 998 例病例没有严重的病态。根据 WHO 标准，检测到 27 例 MNM，而 Waterstone 和基于文献的标准分别识别出 123 例和 153 例。在被 WHO 标准归类为“阴性”而被 Waterstone 或基于文献的标准归类为“阳性”的 130 例病例中，有 119 例存在高血压疾病（91.5%）。此外，由于急性血小板减少症（血小板<50,000），有 4 例仅被 WHO 标准识别出来。Waterstone 和基于文献的方法的敏感性、特异性、准确性和阴性预测值均高于 75%，但两种标准的阳性预测值（PPV）均低于 60%，即使 MNM 的程度较高。
这些结果表明，不同的方法会导致 MNM 的估计值存在差异。Waterstone 和基于文献的标准不适用于 MNM 的明确诊断，因为它们的 PPV 较低，但它们似乎适合作为调查 MNM 的初步方法。这两种替代标准的阴性结果几乎可以排除 MNM，但阳性结果需要使用 WHO 标准重新评估以确认孕产妇近死症的诊断。
