Analysis Of The Cases Of Guangzhou Maternal Transfer And Establishment Of The Maternal Transfer Index

BackgroundMaternal mortality rate is an important indicator of a country or region's social development. Reducing the maternal mortality rate is the important task for obstetrics in 21 century. The contribution of obstetric referrals to maternal morbidity and maternal mortality is important. There has not yet found materials focusing on the safety assessment of maternal transportation.ChapterⅠAnalysis of the cases of Guangzhou maternal transferObjectiveTo study the characteristics of the critically ill obstetric patients who transferring from other hospitals to Obstetric Critical Care Center of Guangzhou in the past five years. Summarizing the characteristics and shortcomings, and then giving some advice to reduce the risks during transportation. Materials and Methods This was a retrospective study. In all, 953 critically ill obstetric patients, transporting to Obstetric Critical Care Center of Guangzhou during last 5+ years, were enrolled with analyzable data. The history of coexisting disorders and characteristics of the patients (including age, gestational age before transport, parity, length of hospital stay, ICU length of stay, maternal and perinatal outcomes and others) were collected from the medical records. The APACHEⅡscore was calculated within 24 hours in all those admitted to Obstetric Critical Care Center of Guangzhou. Using SPSS 13.0 statistical software for statistical analysis, normal distribution of measurement data with mean±standard deviation ((x|—)±s) that the application of t test or ANOVA; non-normal distribution of data used in median and range of representation; count data expressed as a percentage, using chi-square test or Fisher exact probability calculation; a P value <0.05 was considered significant.Results1. The primary hospitals accounted for 77.33%, while the tertiary hospitals only specialty hospitals transfer to general hospitals, such as liver disease hospital in Guangzhou, Guangdong Maternal and Child Health Hospital, only accounted for 9.86%. The transportation time was 15 minutes to more than 5 hours, and the maximum distance was about 500km. The hospitals in Guangzhou area accounted for 75% of the referral hospitals.2. In all 953 cases, the most common indications for maternal transport were severe preeclampsia with its complications, postpartum hemorrhage or hemorrhagic shock, infection with pregnancy, heart disease with pregnancy and others. Severe preeclampsia with its complications and postpartum hemorrhage or hemorrhagic shock were responsible for 62.76% of transfer obstetric patients.3. There were 655 antenatal patients, accounting for 68.73%. A major cause of prenatal patients was severe preeclampsia with its complications accounting for 54.35% in a total of 655 cases, and there were 84.27% patients outreach 37 gastational age.4. Maternal mortality was 7.56%, with intracranial hemorrhage (16.67) and multiple organ dysfunction syndrome (MODS) as main causes. The primary reason for MODS was postpartum hemorrhage/hemorrhagic shock (16.67%).5. The maternal mortality rate was significantly higher in those patients who need secondary transport or more, compared with those patients who transport only once (12.5% vs 6.67%, P = 0.015).6. Pre-transfer information that can be obtained and analysable in 456 cases, the maternal mortality was significantly increased in the unstable patients than stable patients before transfer (28.87% vs 3.90%, P = 0.000).7. The outcomes of one-way maternal transport was the same as two-way transfer 8. The records were complete in 605 cases before transfer (63.48%), 308 cases during transfer (32.32%) and 953 cases after transfer (100%). Only 56 cases (8.54%) monitored the fetal heart rate and 21 cases (3.21%) monitored the uterine contraction in all 655 prenatal cases.Conclusion1. The major diseases were severe preeclampsia with its complications, postpartum hemorrhage or hemorrhagic shock in maternal transportation. The antenatal patients accounted for 68.73%.2. The maternal mortality was higher in secondary transfer patients.3. Unstable condition before transfer was related with higher rates of maternal mortality.4. The document data records before transfer or during transfer were imperfect and the monitor of the processes of labor and fetal was not enough, which may relate with higher transit risk. It's necessary to improve the transit system and reducing the transit risk.Chapter II Establishing of maternal transfer index and evaluating the effectiveness of the maternal transfer index SectionⅠEstablishing of maternal transfer l index ObjectiveEstablishing assessment system for maternal transportaion– maternal transfer index. Objectively and accurately assessment of maternal severity of illness before transfer may be reduced the risk of their transfer, thus reducing maternal mortality. Materials and methodsAccording to APACHEⅡand prognosis system for the critically ill obstetric patients, we establish the maternal transfer index. Select the pulse rate, blood pressure, respiratory rate, blood oxygen saturation, conscious state, and platelet count as the parameters. ResultsThe maternal transfer index concluded six parameters: pulse rate, blood pressure, respiratory rate, blood oxygen saturation, conscious state and platelet count, each parameter assigned from 0 to 5 points, the lowest score of 0 points and the maximum total score of 26 points. Logistic regression analysis showed the six indicators were all associated with the outcomes.SectionⅡEvaluation the effectiveness of the maternal transfer index ObjectiveTo evaluate the effectiveness of the transfer index in critically ill obstetric patients before transportation, and give clinical recommendations. Materials and methodsRetrospectively collected data from July 1, 2004 to December 31, 2009 in Obstetric Critical Care Center of Guangzhou, there were 456 analyzable cases enrolled that transported from other hospitals. The maternal transfer index (including blood pressure, respiratory rate, pulse rate blood oxygen saturation, conscious state, and platelet count) was calculated before and after transportation, and APACHEⅡscore within 24 hours of admission was also calculated. And analysis of the relationship of the maternal transfer index score and maternal outcomes, to give advice for clinical treatment.Results1. In all critically ill obstetric patients transferred from other hospitals, there were 456 cases of complete pre-hospital data were available for analysis. Their mean maternal transfer index score before transfer was 3.95±2.59, and 3.97±2.73 after transfer, T test P = 0.950; their mean APACHEⅡscore within 24 hours of admission was 7.37±4.40.2. The average maternal transfer index score and APACHEⅡscore within 24 hours of admission were significantly higher in those patients who died, compared with survivors, P <0.05.3. The maternal transfer index score before transfer was related with the APACHEⅡscore within 24 hours of admission, the coefficient R = 0.665, P = 0.000. The maternal transfer index score after transfer was also related with the APACHEⅡscore within 24 hours of admission, the coefficient R = 0.833, P = 0.000.4. The goodness of fit test of the transfer index score before transfer is well, P = 0.110. The area under the ROC curve of transfer index was 0.921±0.020 before transfer, and 0.967±0.037 after transfer, and the area under the ROC curve of APACHEⅡscore was 0.930±0.031. There was no difference between the two scores. 5. The maternal transfer index score less than 4 points had no one died, and all were died when the score≥16 points. The maternal mortality and admission of ICU were significantly increased when the maternal transfer index score≥8 points than <8 points. When the maternal transfer index score≥11 points, all pateints were admitted in ICU and with more than two organs dysfunction.Conclusion1. Established the maternal transfer index.2. The maternal transfer index can effectively evaluate the severity of the critically ill obstetric patients before transportaion.3. Possible clinical recommendations: 0-3 points: It is safe for transportation. 4-7 points: It is recommended to take care of the patients during transportation, especially the system which earned the score. 8-10 points: It is recommended immediate give some pretreatment before transfer and give life support if necessary.≥11 points: It is recommended for emergency treatment in situ, after stable of the condition and evaluated again then decided transport to the ICU of the tertiary hospital.