From the Departments of Anesthesiology.
Obstetrics and Gynecology.
Anesth Analg. 2020 Sep;131(3):857-865. doi: 10.1213/ANE.0000000000004605.
A leading cause of preventable maternal death is related to delayed response to clinical warning signs. Electronic surveillance systems may improve detection of maternal morbidity with automated notifications. This retrospective observational study evaluates the ability of an automated surveillance system and the Maternal Early Warning Criteria (MEWC) to detect severely morbid postpartum hemorrhage (sPPH) after delivery.
The electronic health records of adult obstetric patients of any gestational age delivering between April 1, 2017 and December 1, 2018 were queried to identify scheduled or unscheduled vaginal or cesarean deliveries. Deliveries complicated by sPPH were identified and defined by operative management of postpartum hemorrhage, transfusion of ≥4 units of packed red blood cells (pRBCs), ≥2 units of pRBCs and ≥2 units of fresh-frozen plasma, transfusion with >1 dose of furosemide, or transfer to the intensive care unit. The test characteristics of automated pages and the MEWC for identification of sPPH 24 hours after delivery were determined and compared using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) and their 95% confidence intervals (CIs). McNemar test was used to compare these estimates for both early warning systems.
The average age at admission was 30.7 years (standard deviation [SD] = 5.1 years), mean gestational age 38 weeks 4 days, and cesarean delivery accounted for 30.0% of deliveries. Of 7853 deliveries, 120 (1.5%) were complicated by sPPH. The sensitivity of automated pages for sPPH within 24 hours of delivery was 60.8% (95% CI, 52.1-69.6), specificity 82.5% (95% CI, 81.7-83.4), PPV 5.1% (95% CI, 4.0-6.3), and NPV 99.3% (95% CI, 99.1-99.5). The test characteristics of the MEWC for sPPH were sensitivity 75.0% (95% CI, 67.3-82.7), specificity 66.3% (95% CI, 65.2-67.3), PPV 3.3% (95% CI, 2.7-4.0), and NPV 99.4% (95% CI, 99.2-99.6). There were 10 sPPH cases identified by automated pages, but not by the MEWC. Six of these cases were identified by a page for anemia, and 4 cases were the result of vital signs detected by the bedside monitor, but not recorded in the patient's medical record by the bedside nurse. Therefore, the combined sensitivity of the 2 systems was 83.3% (95% CI, 75.4-89.5).
The automated system identified 10 of 120 deliveries complicated by sPPH not identified by the MEWC. Using an automated alerting system in combination with a labor and delivery unit's existing nursing-driven early warning system may improve detection of sPPH.
可预防的产妇死亡的一个主要原因与对临床警告信号的延迟反应有关。电子监测系统可以通过自动通知来提高对产妇发病率的检测。本回顾性观察研究评估了自动监测系统和产妇早期预警标准（MEWC）在产后检测严重产后出血（sPPH）的能力。
查询 2017 年 4 月 1 日至 2018 年 12 月 1 日期间接受任何孕周阴道或剖宫产分娩的成年产科患者的电子健康记录，以确定计划性或非计划性阴道或剖宫产分娩。sPPH 并发症通过产后出血的手术处理、≥4 单位浓缩红细胞（pRBC）输注、≥2 单位 pRBC 和≥2 单位新鲜冷冻血浆输注、输注>1 剂量呋塞米或转入重症监护病房来识别。使用敏感性、特异性、阳性预测值（PPV）和阴性预测值（NPV）及其 95%置信区间（CI）来确定和比较自动页面和 MEWC 在产后 24 小时识别 sPPH 的检测特征，并使用 McNemar 检验比较这两种早期预警系统的这些估计值。
入院时的平均年龄为 30.7 岁（标准差[SD] = 5.1 岁），平均孕龄为 38 周 4 天，剖宫产占分娩的 30.0%。在 7853 例分娩中，有 120 例（1.5%）发生 sPPH 并发症。自动页面在产后 24 小时内检测 sPPH 的敏感性为 60.8%（95%CI，52.1-69.6），特异性为 82.5%（95%CI，81.7-83.4），PPV 为 5.1%（95%CI，4.0-6.3），NPV 为 99.3%（95%CI，99.1-99.5）。MEWC 检测 sPPH 的检测特征为敏感性 75.0%（95%CI，67.3-82.7），特异性 66.3%（95%CI，65.2-67.3），PPV 3.3%（95%CI，2.7-4.0），NPV 99.4%（95%CI，99.2-99.6）。有 10 例 sPPH 病例通过自动页面发现，但未通过 MEWC 发现。其中 6 例是由贫血页面发现的，4 例是床边监护器检测到的生命体征，但床边护士未在患者病历中记录。因此，这两个系统的联合敏感性为 83.3%（95%CI，75.4-89.5）。
自动系统发现了 120 例 sPPH 并发症中有 10 例未被 MEWC 发现。使用自动报警系统与分娩单位现有的护理驱动的早期预警系统相结合，可能会提高 sPPH 的检测率。
