Introduction Medical disorders complicating pregnancy have recently emerged as the most common cause for maternal morbidity and mortality and it is important to predict mortality risk when they present in moribund state to emergency obstetric care so as to take and timely effective measures to prevent mortality.
Methods This prospective observational study was conducted over 6 months among pregnant and post-partum women with medical disorders who sought emergency obstetric care at a tertiary care hospital. Severity of morbidity was assessed using SOFA and APACHE II scores at admission.
Results Of the 128 women, 87.5% were pregnant, and 12.5% were post-partum. Hypertensive disorders, cardiac disorders, neurological disorders and infective disorders were 24.2%, 22.6%, 14% and 9.4%, respectively. The optimal cut-off SOFA score was 2 (AUC = 0.739) with 66% sensitivity and 71% specificity and APACHE II score cut-off was 6 (AUC = 0.732) with a sensitivity of 60% and specificity of 78% in predicting severe maternal morbidity. The median scores of APACHE II and SOFA are 14 and 4, respectively, for non-survivors and for survivors it was 4 and 1.
Conclusion Hypertensive disorder was the most common medical disorder, but severity was high in cardiac disorder. SOFA and APACHE II scores are good predictors of morbidity and mortality risk.
Keywords : Medical disorders · Emergency obstetric care · APACHE II · SOFA score · Maternal mortality
Medical problems may interfere with the physiologic adaptations of pregnancy and cause poor pregnancy outcomes. In the current scenario, pregnant women with medical disorders are increasing, mainly due to demographic, lifestyle factors and most often get referred to tertiary care with complications. The later age of getting married and advanced age at conception are the main factors. Mothers and Babies: Reducing Risk through Audits and Confidential E enquiries (MBRRACE) report in 2011–2013 reported that two-thirds of maternal deaths were in women with medical comorbidities [1]. Identifying and predicting mortality risks will help in providing better care. SOFA (Sequential Organ Failure Assessment) and APACHE II (Acute Physiology And Chronic Health Evaluation II) scores are scores used in critical patients in intensive care unit to predict the acute mortality risk. APACHE II score (range from 0 to 71) was derived from 12 physiologic measurements which includes temperature, blood pressure, heart rate, respiratory rate, arterial pH, oxygenation, serum sodium, potassium and creatinine, haematocrit, white blood cell count and Glasgow coma score, in addition to chronic health status and age of the patient. SOFA score (range from 0 to 24) includes platelet, hepatic, respiratory, renal, cardiovascular and central nervous system functions. The objectives of this study were: (1.) to know the type and proportion of pregnant women with medical disorders seeking emergency care and (2.) to predict mortality risk by using SOFA (Sequential Organ Failure Assessment) and APACHE II (Acute Physiology and Chronic Health Evaluation II) scores. The purpose of predicting mortality risk in these women is to provide effective and timely multidisciplinary care and also to counsel the attendants of the women regarding the seriousness of the condition and take informed consent.
This prospective observational study was conducted from April 2021 to September 2021 after obtaining ethical clearance (JIP/IEC/2021/059). All pregnant and post-partum women (up to 6 weeks) with medical disorders who attended Emergency obstetric services at Women and Child Hospital (with dedicated obstetric ICU facility), JIPMER, Puducherry, were included in the study.
There were a total of 4781 deliveries during this study period of six months. A total of 128 patients with medical disorders who approached for emergency obstetric care in the Department of Obstetrics and Gynaecology, JIPMER, were recruited and analysed.
Table 1 represents the clinicodemographic profile of subjects. The majority of women were in the age group of 20–25 years and mean age of 26.4 ± 4.9 years. BMI was in the normal range in 57% and the mean BMI of 23.0633 ± 0.669 kg/m2. Most of the women (55.46%) were in the upper–lower socio-economic class according to modified Kuppusamy classification and the majority (82%) resided in rural areas. Referral cases constituted 76.56% and they were referred from various hospitals including medical colleges, district hospitals, private hospitals and primary health centres for further management. Pregnant women constituted 87.5% at the time of admission and the rest were post-partum women delivered elsewhere.
