Comparison between near miss criteria in a maternal intensive care unit

The aim of this study was to compare the incidence of different criteria of maternal near miss in women admitted to an obstetric intensive care unit and their sensitivity and specificity in identifying cases that have evolved to morbidity.

Method:

A cross-sectional analytical epidemiological study was conducted with women admitted to the intensive care unit of the Maternity School Assis Chateaubriand in Ceará, Brazil. The Chi-square test and odds ratio were used.

Results:

560 records were analyzed. The incidence of maternal near miss ranged from 20.7 in the Waterstone criteria to 12.4 in the Geller criteria. The maternal near-miss mortality ratio varied from 4.6:1 to 7.1:1, showing better index in the Waterstone criteria, which encompasses a greater spectrum of severity. The Geller and Mantel criteria, however, presented high sensitivity and low specificity. Except for the Waterstone criteria, there was an association between the three other criteria and maternal death.

Conclusion:

The high specificity of Geller and Mantel criteria in identifying maternal near miss considering the World Health Organization criteria as a gold standard and a lack of association between the criteria of Waterstone with maternal death.

DESCRIPTORS
Near Miss; Healthcare; Maternal Mortality; Morbidity; Obstetric Nursing; Intensive Care Units

MANTEL	WATERSTONE
Pulmonary edema	Severe pre-eclampsia
Cardiorespiratory arrest	Eclampsia
Hypovolemia (≥5 unit)	HELLP syndrome
Intubation / Ventilation>60min	Severe bleeding
Oxygen saturation < 90%	Severe sepsis
PaO2/FiO₂ < 300mmHg	Uterine rupture
Oliguria	GELLER
Urea / Creatinine > 400mmol/L	Organic insufficiency
Jaundice + Pre-eclampsia	Transfusion (≥3 unit)
Thyrotoxic crisis	Prolonged intubation (>12h)
Acute thrombocytopenia	Surgical intervention
Coma for more than 12 hours
Subarachnoid hemorrhage / Intraparenchymal
Emergency hysterectomy
WHO (Management)	WHO (Clinical)
Continuous use of vasoactive drugs	Shock
Cardiopulmonary resuscitation	Cardiac arrest
Intubation/ventilation >60 min, not related to anesthesia	Acute cyanosis
Dialysis for acute renal failure	Gasping breathing
Large blood transfusion / red blood cells (≥5 unit)	Respiratory rate >40 or < 6/min
Hysterectomy (hemorrhage or infection)	Oliguria nonresponsive
WHO (Laboratory)	Coagulation failure
Severe hypoperfusion	Jaundice + pre-eclampsia
Severe acidosis (pH < 7.1)	Prolonged loss of consciousness
Oxygen saturation < 90%	Stroke
PAO2/FiO₂ <200mmHg	Total paralysis
Creatinine ≥ 3.5mg/dl	Uncontrollable seizures
Acute thrombocytopenia

INDICATORS	WHO	MANTEL	WATERSTONE	GELLER
Absolute number of cases of MNM¹ 1 Absolute number of cases of MNM;	215	211	347	208
Incidence of MNM² 2 MNM/1.000 live births;	12.8	12.6	20.7	12.4
MNM ratio³ 3 (MNM+Maternal mortality)/1.000 live births;	15.5	15.3	22.4	15.0
MNM ratio: Mortality⁴ 4 NM: 1 Maternal mortality;	4.7:1	4.6:1	7.7:1	4.6:1
Mortality rate⁵ 5 Maternal mortality/(MNM+Maternal mortality);	17.3%	17.5%	12%	17.9%
Maternal mortality ratio in ICU⁶ 6 Maternal mortality/100,000 live births.	263.5/100,000 live births

MANTEL	N	%	WHO (Clinical)	n	%
Pulmonary edema	62	11.1	Shock	106	18.9
Cardiorespiratory arrest	50	8.8	Cardiac arrest	50	8.8
Hypovolemia (≥5 unit)	56	9.9	Acute cyanosis	1	0.2
Intubation/ventilation>60min	117	20.9	Gasping breathing	5	0.9
Oxygen saturation < 90%	16	2.8	Respiratory rate >40 or < 6/min	8	1.4
PaO2/FiO₂ < 300mmHg	6	1.1	Oliguria nonresponsive	46	8.1
Oliguria	46	8.1	Coagulation failure	5	0.9
Urea/creatinine > 400mmol/L	21	3.8	Jaundice + pre-eclampsia	19	3.4
Jaundice + Pre-eclampsia	19	3.4	Prolonged loss of consciousness	22	3.9
Thyrotoxic crisis	1	0.1	Stroke	3	0.5
Acute thrombocytopenia	43	7.6	Total paralysis	4	0.7
Coma for more than 12 hours	22	3.9	Uncontrollable seizures	11	1.9
Subarachnoid hemorrhage/intraparenchymal	3	0.5	WHO (Laboratory)	n	%
Emergency hysterectomy	34	6.1	Severe hypoperfusion	1	0.2
WATERSTONE	N	%	Severe acidosis (pH < 7.1)	16	2.8
Severe pre-eclampsia	172	29.6	Oxygen saturation < 90%	16	2.8
Eclampsia	125	22.7	PAO2/FiO₂ <200mmHg	6	1.1
HELLP syndrome	90	16.1	Creatinine ≥ 3.5mg/dl	13	2.3
Severe bleeding	41	8.5	Acute thrombocytopenia	43	7.6
Severe sepsis	44	7.4	WHO (Management)	n	%
Uterine rupture	2	1.2	Continuous use of vasoactive drugs	95	16.7
GELLER	N	%	Cardiopulmonary resuscitation	45	7.9
Organic insufficiency	165	29.5	Intubation/ventilation >60 min, not related to anesthesia	117	20.9
Transfusion (≥3 unit)	81	14.5	Dialysis for acute renal failure	40	7.0
Prolonged intubation (>12h)	117	20.9	Large blood transfusion / red blood cells (≥5 unit)	56	9.9
Surgical intervention	104	18.6	Hysterectomy (hemorrhage or infection)	34	6.1

Other criteria	WHO Criteria^a a WHO criteria for diagnosing MNM cases was employed as reference (reference standard). ,^b b In parentheses: 95% confidence intervals.		Sensitivity	Specificity
Other criteria	Yes	No	Sensitivity	Specificity
GELLER
Near miss	198 (78.9)	53 (21.1)	76.2 (70.6–80.9)	82.7 (78.1-86.6)
No near miss	62 (19.6)	255 (80.4)	76.2 (70.6–80.9)	82.7 (78.1-86.6)
WATERSTONE
Near miss	185 (49.5)	189 (50.5)	71.2 (65.3–76.3)	38.6 (33.3–44.2)
No near miss	75 (38.7)	119 (61.3)	71.2 (65.3–76.3)	38.6 (33.3–44.2)
MANTEL
Near miss	220 (85.9)	36 (14.1)	84.6 (79.7–88.4)	88.3 (84.2-91.4)
No near miss	40 (12.8)	272 (87.2)	84.6 (79.7–88.4)	88.3 (84.2-91.4)

Criterion	Maternal death	P value ^* * Pearson's chi-square.	OR (CI 95%)
WHO
Yes	45 (17.3)	<0.001	–
No	–
MANTEL
Yes	45 (17.6)	<0.001	–
No	–
WATERSTONE
Yes	27 (7.2)	0.314	0.7 (0.3-1.3)
No	18 (9.7)
GELLER
Yes	43 (17.1)	<0.001	31.7 (7.6-132.4)
No	2 (0.6)

Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br

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[1] Corresponding author: Alana Santos Monte Rua Alexandre Baraúna, 1115 - Rodolfo Teófilo CEP 60416-000 – Fortaleza, CE, Brazil alanasmonte@yahoo.com.br