Edwards Sian E, Grobman William A, Lappen Justin R, Winter Cathy, Fox Robert, Lenguerrand Erik, Draycott Timothy
School of Clinical Sciences, University of Bristol, Bristol, United Kingdom.
Feinberg School of Medicine, Northwestern University, Chicago, IL.
Am J Obstet Gynecol. 2015 Apr;212(4):536.e1-8. doi: 10.1016/j.ajog.2014.11.007. Epub 2014 Nov 8.
We sought to compare the predictive power of published modified obstetric early warning scoring systems (MOEWS) for the development of severe sepsis in women with chorioamnionitis.
This was a retrospective cohort study using prospectively collected clinical observations at a single tertiary unit (Chicago, IL). Hospital databases and patient records were searched to identify and verify cases with clinically diagnosed chorioamnionitis during the study period (June 2006 through November 2007). Vital sign data (heart rate, respiratory rate, blood pressure, temperature, mental state) for these cases were extracted from an electronic database and the single worst composite recording was identified for analysis. Global literature databases were searched (2014) to identify examples of MOEWS. Scores for each identified MOEWS were derived from each set of vital sign recordings during the presentation with chorioamnionitis. The performance of these MOEWS (the primary outcome) was then analyzed and compared using their sensitivity, specificity, positive and negative predictive values, and receiver-operating characteristic curve for severe sepsis.
Six MOEWS were identified. There was wide variation in design and pathophysiological thresholds used for clinical alerts. In all, 913 women with chorioamnionitis were identified from the clinical database. In all, 364 cases with complete data for all physiological indicators were included in analysis. Five women developed severe sepsis, including 1 woman who died. The sensitivities of the MOEWS in predicting the severe deterioration ranged from 40-100% and the specificities varied even more ranging from 4-97%. The positive predictive values were low for all MOEWS ranging from <2-15%. The MOEWS with simpler designs tended to be more sensitive, whereas the more complex MOEWS were more specific, but failed to identify some of the women who developed severe sepsis.
Currently used MOEWS vary widely in terms of alert thresholds, format, and accuracy. Most MOEWS have not been validated. The MOEWS generally performed poorly in predicting severe sepsis in obstetric patients; in general severe sepsis was overdetected. Simple MOEWS with high sensitivity followed with more specific secondary testing is likely to be the best way forward. Further research is required to develop early warning systems for use in this setting.
我们试图比较已发表的改良产科早期预警评分系统（MOEWS）对绒毛膜羊膜炎女性发生严重脓毒症的预测能力。
这是一项回顾性队列研究，使用了在单一三级医疗单位（伊利诺伊州芝加哥）前瞻性收集的临床观察数据。检索医院数据库和患者记录，以识别和验证研究期间（2006年6月至2007年11月）临床诊断为绒毛膜羊膜炎的病例。这些病例的生命体征数据（心率、呼吸频率、血压、体温、精神状态）从电子数据库中提取，并确定单次最差的综合记录进行分析。检索全球文献数据库（2014年）以识别MOEWS的实例。每个识别出的MOEWS的评分来自绒毛膜羊膜炎发作期间的每组生命体征记录。然后使用这些MOEWS的敏感性、特异性及阳性和阴性预测值以及严重脓毒症的受试者工作特征曲线，对其性能（主要结局）进行分析和比较。
识别出6个MOEWS。用于临床警报的设计和病理生理阈值存在很大差异。总共从临床数据库中识别出913例绒毛膜羊膜炎女性。总共364例所有生理指标数据完整的病例纳入分析。5名女性发生严重脓毒症，其中1名女性死亡。MOEWS预测严重病情恶化的敏感性范围为40%-100%，特异性差异更大，范围为4%-97%。所有MOEWS的阳性预测值都很低，范围为<2%-15%。设计更简单的MOEWS往往更敏感，而更复杂的MOEWS更具特异性，但未能识别出一些发生严重脓毒症的女性。
目前使用的MOEWS在警报阈值、形式和准确性方面差异很大。大多数MOEWS尚未经过验证。MOEWS在预测产科患者严重脓毒症方面通常表现不佳；总体而言，严重脓毒症被过度检测。具有高敏感性的简单MOEWS随后进行更具特异性的二次检测可能是最佳方法。需要进一步研究以开发适用于此情况的早期预警系统。
