Maternal sepsis represents the third cause of maternal mortality worldwide and the diagnosis delay portrays a great contribution due to its high lethality. The Modified Early Obstetric Warning System is an early detection tool validated in maternal sepsis scenarios. This, to recognize a deteriorating condition in gestating women with a high risk of maternal collapse and determine the rapid response team leading the patients’ treatment. This report will describe the incorporation of this strategy for the evaluation of distant pregnant septic patients. Present three cases of obstetric patients with clinical suspicion of sepsis initially admitted to a second level hospital assessed through telemedicine from a high complexity obstetric unit applying the early detection tool for risk stratification (determined by a score ≥6) and guidance of clinical management before the transfer to a fourth level complexity center.
Obstetric sepsis is a potentially mortal organ dysfunction induced by a host's dysregulated response to infection during pregnancy, delivery, or the postpartum period.1,2 It is the third cause of maternal mortality worldwide and delays in the diagnosis or treatment contribute to this mortality,3,4 particularly given the high lethality rate of sepsis compared to other obstetric emergencies.5 One of the strategies proposed to reduce this impact is the implementation of clinical instruments based on the identification of abnormal signs and symptoms that allow the early detection of patients who could require aggressive interventions or transfer to higher complexity centers. These are known as Early Warning Systems.6 The Modified Early Obstetric Early Warning System (MEOWS) assigns weighted values to arterial pressure, heart rate, respiratory rate, supplementary oxygen requirement, and state of consciousness, according to their degree of deviation from the normality, to establish a score with aims to determine the severity of the patient's clinical condition and determine the need of alerting the rapid response team (Fig. 1). When the value is ≥6 means the patient requires management by obstetric critical care trained team (Fig. 2).7
Telemedicine allows the use of medical information exchanged from one place to another through electronic communication to improve the patient's health8 and its use has been recently introduced in Latin American countries. The application of the MEOWS to determine the clinical severity in obstetric patients with sepsis admitted to a low complexity center to start treatment promptly and establish a timely transfer to a higher complexity center through telemedicine has not been yet reported. The following case series sets this process as an innovative strategy to reduce maternal mortality in southwest Colombia.
A 24-year-old patient gravida 3, cesarean 1, para 1, abortus 1, 20 weeks of gestation with home birth in distant rural area who presents postpartum hemorrhage and obstetric sepsis secondary to chorioamnionitis was first admitted to secondary care (Hospital Francisco de Paula Santander (HFPS)) febrile, tachycardic, hypotensive (70/30 mm Hg) and stuporous, with a MEOWS score of 13. The case was commented to Fundación Valle de Lili (FVL) through the telemedicine service. According to the MEOWS, stabilization by the implementation of postpartum hemorrhage checklist, fluid resuscitation, early administration of vasoactive agents (Norepinephrine), broad-spectrum antibiotics, and transfusion of two units of red blood cells (hemoglobin: 7 g/L) were indicated. The clinical management was continuously monitored by a video call from the FVL. The patient was transferred 1 hour after admission and it took 45 minutes. At admission to the FVL, she was alert, oriented, normotensive and afebrile, with a MEOWS score of 1. A septic abortion with mixed shock (hypovolemic/septic) was considered; she was taken to obstetric curettage and was discharged after the fourth day of hospitalization.
A 25-year-old patient gravida 1, para 0; presented to HFPS for abdominal pain, emesis, uterine activity, and fever (40°C). The patient was tachycardic (128 bpm), tachypneic (28 breaths/minutes) and hypotensive (90/55 mm Hg) with a MEOWS score of 7 at admission. Laboratory findings showed leukocytosis (194 × 109/L) with neutrophilia (85%) and elevated C-reactive protein 102 mg/L. The case was commented through the telemedicine service of FVL with the clinical diagnosis of obstetric-associated septic shock. Fluid resuscitation, broad-spectrum antibiotics, and emergent transfer to a fourth level hospital were indicated. The transfer took 1 hour and 40 minutes and she had a MEOWS score of 2 at admission. Urinary sepsis was confirmed, antibiotic therapy was continued and she was later transferred to a lower complexity center after 2 days of hospitalization with adequate clinical response.
A 22-year-old patient, gravida 5, abortus 3, cesarean 1, 12+4 weeks of gestation who presented to HFPS for abundant fetid amniorrhea, fever, cephalea, and pelvic pain. At admission, she was tachycardic, hypotensive, and afebrile with a MEOWS score of 6 with clinical evidence of incomplete septic abortion. The case was commented through the telemedicine service, with the indication of antibiotic therapy, fluid resuscitation with crystalloids, vasoactive support with Norepinephrine and emergent transfer to a quaternary care. Transfer took 1 hour and 51 minutes, with a MEOWS score of 0 at admission to the higher complexity hospital. Obstetric curettage was performed after fetal expulsion and she was discharged after the 5th day of hospitalization.
The use of digital technologies for health (Digital health – eHealth) is a growing practice that uses technological information and communication in a routinely and innovative manner to improve the needs in health. The World Health Assembly Resolution on Digital Health approved by the members of the World Health Organization in May 2018 recognized the value of these digital technologies to contribute to the sustainable development goals achievement, including reducing maternal mortality.9 In 2019, the World Health Organization published the recommendations on digital interventions for health system strengthening, establishing the use of telemedicine between qualified and certified hospitals where security, privacy, traceability, and accountability can be monitored. In this context, monitoring patients include creating standardized operative procedures to prescribe medical protocols from distance.
Additionally, there's an urgent need to strengthen telehealth especially to facilitate the decision-making process of medical personnel in rural or distant hospitals that encounter patients in critical conditions.10 The Agency for Healthcare Research and Quality report with 58 systematic reviews provides evidence in the effectiveness of the remote monitoring of patients. This report also sustains the development of evidence about assisted teleconsult, particularly in the management of critically ill patients and the application in the obstetric critical care.
The standardized models of telemedicine in low complexity hospitals to aid in the management of critically ill obstetric patients are scarce. Although these reports have demonstrated that a telehealth coordinated team allows the performance of effective and prompt interventions in rural hospitals with aims to stabilize and transfer critically ill patients on time. Through technology, doctors and nurses from hospitals of middle-low income countries can access education strategies for the management of obstetric emergencies. Ideally, before the implementation of telemedicine, training should include simulation activities for the management of obstetric emergencies in the rural setting.
According to this, and following the qualification system of Colombia's health department, FVL and HFPS carried out a program of Tele-education in obstetric emergencies and established the telemedicine service as a strategy to reduce the maternal mortality since 2017. As an innovative approach, the MEOWS was implemented to characterize objectively the obstetric patients commented through such service and was designed to determine the severity of a patient's condition during the first 24 hours after admission, favoring the prompt transfer to the proper services and reassuring timely interventions as intensive care unit admission. These rapid interventions associate with a decrease in mortality when treatment starts at the emergency services.
The obstetric population's physiological changes account for variations in most of the items included in the Early Warning Systems, that is why the MEOWS was adapted for obstetric population and is recommended for pregnant or postpartum women with an ongoing critical condition.7 The MEOWS provides the most solid evidence for the recognition of the acutely ill gestating patients, especially for those hospitalized. This system uses a color code according to the alarm symptoms that must be identified by the nursing staff (Figs. 2, 3). When the MEOWS is implemented, obstetric conditions that may be causing the abnormalities should be considered, as well as potential previous comorbidities to reach the right diagnosis. In general terms, it has a sensitivity of 89% (95% confidence interval: 81%–95%) and a specificity of 79% (95% confidence interval: 76%–82%) for intensive care unit admission.4 In highly lethal conditions such as sepsis, identifying its severity determines the patient's outcome.
For the treatment of obstetric sepsis, the goal is to initiate treatment promptly and stabilize the patient, seeking to stop the progression to septic shock and improving tissue perfusion to limit cellular dysfunction. In a setting lacking evidence-based management recommendations in pregnancy, the best option is to follow the surviving sepsis campaign guidelines. In 2018, the Hour-1 Bundle was published, a novel strategy that suggested a bundle of interventions to carry out during the first hour of treatment. These recommendations should be considered as an opportunity to improve the quality of attention and decrease the time of intervention, actions that are key to the treatment of patients with sepsis or septic shock. The recommended interventions in this period of time are: measurement of lactate levels, obtainment of blood cultures before the administration of antibiotics, administration of broad-spectrum antibiotics, rapid fluid resuscitation with 30 mL/kg crystalloid for hypotension or lactate level ≥4 mmol/L and application of vasopressor agents in case of hypotension during or after fluid resuscitation to maintain mean arterial pressure ≥65 mm Hg.
The knowledge of these interventions in rural hospitals and low complexity centers is usually limited, hence the need for collaboration with higher complexity hospitals. This connection assures quality, establishes confidence between teams, improves teaching processes and it's thought to decrease maternal mortality.
The use of conjoined objective strategies for the detection of clinical severity for gestating women with high risk of mortality, with strategies of accompaniment in the treatment from distance to lead the patient's transfer, the experience reported establishes a new opportunity of research in a growing area as telemedicine.
The authors thank all the medical and administrative staff of HFPS for their commitment to the implementation of telemedicine as a new strategy of improvement and quality.
Conflicts of Interest
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. World Health Organization. WHO Guideline: Recommendations on Digital Interventions for Health System Strengthening. Executive Summary. 2019. Available at: https://www.who.int/publications-detail/who-guideline-recommendations-on-digital-interventions-for-health-system-strengthening
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