Shock index thresholds to predict adverse outcomes in maternal hemorrhage and sepsis: A prospective cohort study.

Authors:
Hannah L Nathan
Hannah L Nathan
King's College London
Paul T Seed
Paul T Seed
King's College London
United Kingdom
Natasha L Hezelgrave
Natasha L Hezelgrave
King's College London School of Medicine
United Kingdom
Elodie Lawley
Elodie Lawley
Schepens Eye Research Institute
United States
John Anthony
John Anthony
University of Kentucky
United States
Wilhelm Steyn
Wilhelm Steyn
Tygerberg Hosptial and Stellenbosch University
South Africa
David R Hall
David R Hall
Boston University
United States

Acta Obstet Gynecol Scand 2019 Apr 18. Epub 2019 Apr 18.

Department of Women and Children's Health, King's College London, London, UK.

Introduction: Shock index (SI) is a predictor of hemodynamic compromise in obstetric patients. The SI threshold for action is not well understood. We aimed to evaluate SI thresholds as predictors of outcomes in obstetric patients.

Material And Methods: We undertook a prospective cohort study at three South African hospitals of women with postpartum hemorrhage (n = 283) or maternal sepsis (n = 126). The "first" and "worst" SI following diagnosis were recorded. SI was compared with conventional vital signs as predictors of outcomes. The performance of SI <.9, SI .9-1.69 and SI ≥1.7 to predict outcomes (maternal death; Critical Care Unit admission; major procedure; hysterectomy) and hemorrhage-specific outcomes (lowest hemoglobin <70 g/l; blood transfusion ≥4 IU) were evaluated.

Results: "First" SI was one of two best performing vital signs for every outcome in postpartum hemorrhage and sepsis. In hemorrhage, risk of all outcomes increased with increasing "first" SI; for blood transfusion ≥4 IU odds ratio was 4.24 (95% confidence interval 1.25-14.36) for SI ≥1.7 vs SI .9-1.69. In sepsis, risk of all outcomes increased with increasing "worst" SI. Sensitivity, specificity, positive and negative predictive values of "first" SI <.9 vs SI ≥.9 for maternal death were 100.0%, 55.2%, 4.6% and 100.0%, respectively, in hemorrhage and 80.0%, 50.4%, 12.3% and 96.7%, respectively, in sepsis.

Conclusions: The shock index was a consistent predictor of outcomes compared with conventional vital signs in postpartum hemorrhage and sepsis. SI <.9 performed well as a rule-out test and SI .9-1.69 and SI ≥1.7 indicated increased risk of all outcomes in both cohorts. These thresholds may alert to the need for urgent intervention and prevent maternal deaths.

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https://onlinelibrary.wiley.com/doi/abs/10.1111/aogs.13626
Publisher Site
http://dx.doi.org/10.1111/aogs.13626DOI Listing
April 2019
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