Research ajog.

org

1 OBSTETRICS 56
2 57
3
Q1
Modified obstetric early warning scoring 58
4 59
5 systems (MOEWS): validating the diagnostic 60
6 61
7 performance for severe sepsis in women 62
8 63
9 with chorioamnionitis 64
10 Q12 Sian E. Edwards, MBChB; William A. Grobman, MD, MBA; Justin R. Lappen, MD; 65
11 Q2 Cathy Winter; Robert Fox, MD; Erik Lenguerrand, PhD; Timothy Draycott, MD 66
12 67
13 68
14 OBJECTIVE: We sought to compare the predictive power of published 913 women with chorioamnionitis were identified from the clinical 69
15 modified obstetric early warning scoring systems (MOEWS) for the database. In all, 364 cases with complete data for all physiological 70
16 development of severe sepsis in women with chorioamnionitis. indicators were included in analysis. Five women developed severe 71
17 sepsis, including 1 woman who died. The sensitivities of the MOEWS 72
18 STUDY DESIGN: This was a retrospective cohort study using pro- 73
in predicting the severe deterioration ranged from 40e100% and
19 spectively collected clinical observations at a single tertiary unit 74
the specificities varied even more ranging from 4e97%. The positive
(Chicago, IL). Hospital databases and patient records were searched
20 predictive values were low for all MOEWS ranging from <2e15%. 75
21 to identify and verify cases with clinically diagnosed chorioamnionitis 76
The MOEWS with simpler designs tended to be more sensitive,
22 during the study period (June 2006 through November 2007). Vital 77
whereas the more complex MOEWS were more specific, but failed to
23 sign data (heart rate, respiratory rate, blood pressure, temperature, 78
identify some of the women who developed severe sepsis.
24 mental state) for these cases were extracted from an electronic 79
25 database and the single worst composite recording was identified for CONCLUSION: Currently used MOEWS vary widely in terms of 80
26 analysis. Global literature databases were searched (2014) to identify alert thresholds, format, and accuracy. Most MOEWS have not been 81
27 examples of MOEWS. Scores for each identified MOEWS were derived validated. The MOEWS generally performed poorly in predicting 82
28 from each set of vital sign recordings during the presentation with severe sepsis in obstetric patients; in general severe sepsis was 83
29 chorioamnionitis. The performance of these MOEWS (the primary overdetected. Simple MOEWS with high sensitivity followed with more 84
30 outcome) was then analyzed and compared using their sensitivity, specific secondary testing is likely to be the best way forward. Further 85
31 specificity, positive and negative predictive values, and receiver- research is required to develop early warning systems for use in this 86
32 operating characteristic curve for severe sepsis. setting. 87
33 RESULTS: Six MOEWS were identified. There was wide variation in Key words: chorioamnionitis, early warning systems, patient safety, 88
34 design and pathophysiological thresholds used for clinical alerts. In all, sepsis 89
35 90
36 Cite this article as: Edwards SE, Grobman WA, Lappen JR, et al. Modified obstetric early warning scoring systems (MOEWS): validating the diagnostic performance for 91
37 severe sepsis in women with chorioamnionitis. Am J Obstet Gynecol 2015;212:x.ex-x.ex. 92
38 93
39 94
40
41 S epsis describes a systemic inflam-
matory reaction to infection in
usually sterile tissues.1 It progresses
stage carrying increasing risk of mortal-
ity.2 Maternal sepsis is a leading direct
cause of preventable maternal morbi-
changes of pregnancy can mimic the
early stages of sepsis and can also accel-
erate its progress.4 These factors can
95
96
42 97
43 through a spectrum of severity, each dity and mortality.3 The physiological delay the recognition of sepsis until se- 98
44 vere deterioration has occurred. 99
45 The early detection of sepsis is key 100
Q3 From the Schools of Clinical Sciences (Drs Edwards and Lenguerrand) and Social and Community
46 to optimizing outcomes.4 Early warn- 101
Medicine (Dr Draycott), University of Bristol, and RISQ Research, Southmead Hospital (Ms Winter),
47 ing systems that track observed vital signs 102
Bristol, and Musgrove Park Hospital, Taunton (Dr Fox), United Kingdom; Feinberg School of
48 Medicine, Northwestern University, Chicago, IL (Dr Grobman); and MetroHealth Medical Center, and trigger medical response at threshold 103
49 Case Western Reserve University School of Medicine, Cleveland, OH (Dr Lappen). limits have been developed to improve 104
50 Received July 25, 2014; revised Oct. 8, 2014; accepted Nov. 3, 2014. identification of all patients at risk of 105
51 The authors report no conflict of interest. imminent deterioration, irrespective of 106
52 Presented as a poster at the World Congress of the Royal College of Obstetricians and
their diagnosis. In the nonobstetric 107
53 Gynaecologists, Liverpool, United Kingdom, June 24-26, 2013. population, the modified early warning 108
54 Corresponding author: Sian E. Edwards, MBChB. sian.edwards@doctors.org.uk system (MEWS) has been shown to 109
55 0002-9378/$36.00
ª 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2014.11.007
predict intensive care unit (ICU) transfer 110
and mortality.5,6 However, when the

MONTH 2015 American Journal of Obstetrics & Gynecology 1.e1

FLA 5.2.0 DTD
YMOB10127_proof
17 November 2014
11:58 pm
ce
 Research Obstetrics ajog.org

111 167
112 same system was applied to an obstetric chorioamnionitis during an 18-month transfer, or death. The standard Amer- 168
113 population with infection, the predictive period (June 2006 through November ican College Chest Physicians/Society of 169
114 power was found to be poor.7 In recog- 2007). The hospital perinatal database Critical Care Medicine 2001 consensus 170
115 nition of the altered physiology of preg- was searched for the terms “febrile in definition for severe sepsis was used.16 171
116 nancy, there have been efforts to adapt labor,” “chorioamnionitis,” “therapeutic As a summary measure of the diagnostic 172
117 these systems for use in maternity care, antibiotics,” or “maternal ICU transfer.” performance of each test the receiver- 173
118 and modified obstetric early warning The hospital billing database was operating characteristic (ROC) curve 174
119 systems (MOEWS) have been recom- searched for obstetric cases with was calculated along with the area under 175
120 mended for clinical use.8-10 These are International Classification of Diseases, the ROC (AUROC). 176
121 mostly unvalidated and no single sys- Ninth Revision codes for endomyome- All patient information was abstracted 177
122 tem has been accepted for maternity tritis, chorioamnionitis, or sepsis. A from the electronic patient database 178
123 care.11-15 Therefore, a variety of different care-quality database of patients trans- into an anonymized Microsoft Excel Q4 179
124 MOEWS remain in use. The aim of ferred to intensive care was searched for spreadsheet, and Stata (STATA/IC v13.1; 180
125 this study was to compare the predictive maternity cases with febrile morbidity. StataCorp LP, College Station, TX) was 181
126 power of MOEWS in women with Chorioamnionitis was defined clinically used to generate early warning system 182
127 chorioamnionitis. as maternal pyrexia in labor (38 C) scores from raw vital signs, as well as 183
128 associated with uterine tenderness, ma- to perform all statistical analyses. The 184
129
M ATERIALS AND M ETHODS ternal or fetal tachycardia, or purulent/ Northwestern University Institutional 185
130 Global literature databases (MEDLINE, foul-smelling amniotic fluid. Electronic Review Board approved analysis. 186
131 PubMed) and clinical guidance publi- patient records for all identified cases 187
132 cations were searched to identify work- were manually reviewed by 1 member R ESULTS 188
133 ing examples of early warning systems of the research team to identify cases During the study period, 15,027 189
134 specifically used in maternity care. meeting these inclusion criteria. There births were recorded. A total of 913 cases 190
135 Several different titles were identified for were no specific exclusion criteria. of chorioamnionitis were confirmed 191
136 these early warning scores/charts; for Maternal demographics and obstetric (6.1%). Maternal demographic data and 192
137 consistency we will refer to all of these data (maternal history and peripartum obstetric data for the women are shown 193
138 obstetric systems as MOEWS. MOEWS outcomes) were abstracted from the in Table 2. Of the group of 913 women, ½T2 194
139 were included if they had clear in- patient record. In addition, each set of severe sepsis was observed in 5 women 195
140 structions, in English, such that the vital signs (heart rate, respiratory rate, (0.5%; 95% CI, 0.2e1.3%), including 196
141 scoring system could be easily applied to blood pressure, temperature, mental 1 maternal death due to sepsis. Complete 197
142 a data set of clinical vital sign observa- state) recorded during labor was vital sign data were available for 364 198
143 tions. Six published MOEWS (A-F) were retrieved from the electronic medical patients (including the 5 outcome cases), 199
144 identified representing the 2 most com- record. Measurements taken within 40 and these cases were used for analysis 200
145 mon methods of track-and-trigger early minutes of epidural placement were of MOEWS. 201
146 warning systems: color-coded trigger excluded as transient changes in vital The MOEWS we tested varied wide- 202
147 bands (single/multiple indicator trigger signs could be attributed to this proce- ly in design and pathophysiological 203
148 systems)11-13 and numerical scoring dure. Otherwise, for each woman the thresholds used for clinical alerts. The 204
149 triggers (or aggregate-weighted scoring single worst composite set of recorded test characteristics of each MOEWS 205
150 systems).14,15 The scoring thresholds for vital signs (generating the highest chart for the primary outcome are 206
151 each system investigated in this study are MEWS score) during the admission shown in Table 3. For comparison, this ½T3 207
152½T1 outlined in Table 1. For each early episode was selected. Only cases with table also shows the test characteristics 208
153 warning system, the threshold score complete vital sign data were included in for the previously analyzed MEWS, a 209
154 indicating the highest risk level that the analysis. These vital signs were then validated scoring system for the non- 210
155 should prompt immediate senior medi- used to generate early warning scores obstetric population. There was consid- 211
156 cal review was identified as the trigger according to the instructions for each erable variation in diagnostic power 212
157 and was then used for further analysis. MOEW system, as outlined in Table 1. between each of the MOEWS tested; 213
158 The identified MEOWS (A-F) were Oxygen saturation data were not avail- sensitivities ranged from 40% for 214
159 applied to a vital sign data set generated able and therefore assumed to be normal MOEWS E to 100% for MOEWS A to C, 215
160 from a cohort of women with cho- in each case for analysis. The proportion with low positive predictive values for 216
161 rioamnionitis from a single tertiary care of cases reaching the warning trigger each of the MOEWS, which ranged from 217
162 maternity hospital (Chicago, IL). De- score was calculated for each system with 1.42% (MOEWS C) to 15.4% (MOEWS E). 218
163 tailed information on the methods of 95% confidence intervals (CIs). Test The AUROC ranged from 0.52 219
164 case ascertainment and data retrieval characteristics (sensitivity, specificity, (MOEWS B and C) to 0.72 (MOEWS D) 220
165 has been previously published.7 Briefly, positive predictive value, negative pre- (Figure 1). The distributions of highest ½F1 221
166 multiple search strategies were used dictive value) were calculated for each MOEWS scores for the cases of cho- 222
to identify cases of clinically diagnosed MOEWS trigger for severe sepsis, ICU rioamnionitis are shown in Figure 2. In ½F2

1.e2 American Journal of Obstetrics & Gynecology MONTH 2015

FLA 5.2.0 DTD
YMOB10127_proof
17 November 2014
11:58 pm
ce
 ajog.org Obstetrics Research
223 279
224 280
TABLE 1
225 281
Modified obstetric early warning scoring systems Q9
226 Q10 282
Color-coded MOEWS
227 283
228 MOEWS A12 284
229 Variable Red Amber 0 Amber Red Trigger 285
230 Pulse rate 59 60e69 70e109 110e139 140 Score 2 Ambers 286
231 or 1 Red 287
232 288
Systolic BP 89 90e99 100e149 150e159 160
233 289
234 Diastolic BP 79 80e89 90 290
235 Respiratory rate 10 11e20 21e29 30 291
236 Temperature 34.9 35.0e35.9 36.0e37.9 38e38.9 39.0 292
237 293
O2 Sats 89 90e100
238 294
239 Mental state Alert Voice Pain/unresponsive 295
240 MOEWS B 11 296
241 297
Variable Red Amber 0 Amber Red Trigger
242 298
243 Pulse rate 39 40e49 50e99 100e119 120 Score 2 Ambers 299
or 1 Red
244 300
245 Systolic BP 89 90e99 100e159 160e169 170 301
246 Diastolic BP 99 100e109 110 302
247 Respiratory rate 0e10 11e20 21e29 30 303
248 304
249 Temperature 34.9 35.0e35.9 36.0e37.9 38.0 305
250 O2 Sats 94 95e100 306
251 Mental state Alert Voice Pain/unresponsive 307
252 13 308
MOEWS C
253 309
254 Variable Red Amber 0 Amber Red Trigger 310
255 Pulse rate 39 40e49 50e99 100e119 120 Score 2 Ambers 311
256 or 1 Red 312
257 Systolic BP 89 90e99 100e149 150e159 160 313
258 314
Diastolic BP 89 90e100 100
259 315
260 Respiratory rate 0e10 11e20 21e29 30 316
261 Temperature 34.9 35.0e35.9 36.0e37.9 38.0 317
262 O2 Sats 94 95e100 318
263 319
Mental state Alert Voice Pain/unresponsive
264 320
265 Aggregate score MOEWS 321
266 MOEWS D14 322
267 323
Variable 3 2 1 0 1 2 3 Trigger:
268 324
269 Pulse rate 39 40e59 60e74 75e104 105e109 110e129 130 Medium risk 325
270 Systolic BP 79 80e89 90e139 140e149 150e199 200 Score 4e5 326
271 Respiratory rate 5 5e9 10e14 15e19 20e24 25e29 30 High risk 327
272 328
Temperature 34.9 35.0e35.9 36.0e37.9 38.0e38.4 38.5 Score 6
273 329
274 O2 Sats 87 88e89 90e94 95e100 330
275 Mental state Alert Voice Pain Unresponsive 331
276 332
Edwards. Power of MOEWS for predicting severe sepsis. Am J Obstet Gynecol 2015. (continued)
277 333
278 334

MONTH 2015 American Journal of Obstetrics & Gynecology 1.e3

FLA 5.2.0 DTD
YMOB10127_proof
17 November 2014
11:58 pm
ce
 Research Obstetrics ajog.org

335 391
336 392
TABLE 1
337 393
Modified obstetric early warning scoring systems (continued)
338 394
Aggregate score MOEWS
339 395
340 MOEWS E14 396
341 Variable 3 2 1 0 1 2 3 Trigger: 397
342 398
Pulse rate 39 40e49 50e109 110e119 120e129 130 Medium risk
343 399
344 Systolic BP 69 70e79 80e99 100e149 150e159 160e199 200 Score 4e5 400
345 Diastolic BP 39 40e89 90e99 100e109 110 High risk 401
346 Respiratory rate 5 5e9 10e19 20e24 25e29 30 Score 6 402
347 403
Temperature 34.9 35.0e35.9 36.0e37.9 38.0e38.9 39.0e39.9 40
348 404
349 O2 Sats 95 96e100 405
350 Mental state Alert Voice Pain Unresponsive 406
351 407
MOEWS F15
352 408
353 Variable 3 2 1 0 1 2 3 Trigger: 409
354 Pulse rate 59 60e110 111e149 150 Medium risk 410
355 Systolic BP 79 80e89 90e139 140e149 150e159 160 Score 4 or single 411
356 parameter ¼ 3 412
357 Diastolic BP 89 90e99 100e109 110 High risk trigger 413
358 414
Respiratory rate 9 10e17 18e24 25e29 30 Score 6
359 415
360 Temperature 33.9 34.0e35.0 35.1e37.9 38.0e38.9 39.0 416
361 O2 Sats 94 95e100 417
362 Mental state Alert Voice/pain/unresponsive
418
363 419
MOEWS, modified obstetric early warning scoring systems.
364 420
Edwards. Power of MOEWS for predicting severe sepsis. Am J Obstet Gynecol 2015.
365 421
366 422
367 423
368 424
369 all, 71.4% (95% CI 66.5e76.0%) of cases in these pregnant women with suspected chorioamnionitis in developed set- 425
370 reached the trigger score for MOEWS A, infection. tings.17 Chorioamnionitis was selected 426
371 96.2% (93.6e97.9%) for MOEWS B, as the study group of interest as it rep- 427
96.4% (94.0e98.1%) for MOEWS C, Strengths and limitations resents a common diagnosis during the
372 428
373 16.2% (12.6e20.4%) for MOEWS D, This study utilized electronically col- intrapartum period, which is the focus of 429
374 3.6% (1.9e6.0%) for MOEWS E, and lected clinical observations that were this manuscript. 430
375 9.6% (6.8e13.1%) for MOEWS F. stored prospectively. This system mini- The clinical database used to test 431
376 mized errors in transcription of vital the MOEWS incorporated the vital 432
C OMMENT signs that would usually limit the inter- signs of women in a routine obstetric
377 433
Main findings pretation of data derived from paper- setting, rather than those already
378 434
379 In this study, we identified 6 published based patient charts. The prospective admitted to a critical care area. This is 435
380 early warning systems specifically collection of data also increases the val- important when considering that the 436
381 designed for use in maternity care. The idity of the retrospective review by intended purpose of early warning sys- 437
382 MOEWS had markedly different physi- limiting bias. The study included a large tems is as a screening tool to identify 438
383 ological thresholds, clinical triggers, number of women delivering in a busy patients at imminent risk of deteriora- 439
384 and ability to predict severe worsening tertiary referral unit over an 18-month tion due to acute illness, rather than to 440
385 of obstetric sepsis. In general, they ten- period, and used rigorous multifaceted predict mortality in highly selected 441
386 ded to overdetect severe sepsis (low search criteria to maximize case ascer- groups of those already identified as be- 442
387 positive predictive values), raising the tainment, such that the study sample ing severely unwell. 443
388 need for more specific secondary testing is likely to be representative and our Our study is limited by missing vital 444
389 to identify true cases. None of these findings generalizable to other similar sign values for some patients. This re- 445
390 MOEWS performed as well as the stan- settings. Other studies have reported flects the use of clinically derived data, 446
dard MEWS in predicting deterioration similar rates of clinically diagnosed whereby patient observations are not

1.e4 American Journal of Obstetrics & Gynecology MONTH 2015

FLA 5.2.0 DTD
YMOB10127_proof
17 November 2014
11:58 pm
ce
 ajog.org Obstetrics Research

Q11
447 503
448 imputed median values for missing 504
TABLE 2 data,15 or presumed normality,7,19 we

5.15 (1.69e11.6)

0.95 (0.94e0.96)
449 505

90.4 (87.7e91.8)
Maternal demographic data took a more cautious approach and

Test characteristics of modified obstetric early warning scoring systems charts for primary outcome of severe sepsis or mortality using highest

100 (47.8e100)

100 (99.5e100)
450 506
Variable N [ 913 excluded any patients without the com-
451 507
452 Age, y 29.7  5.8 plete set of 5 clinical variables recorded. 508

MEWS
453 This increases the reliability of the ana- 509
Nulliparous, % 88.5
454 lyses of predictive power performed on 510
Race, % the MOEWS in our study. However,
455 511
456 White 48.8 exclusion of a large number of patients 512

5.71 (0.70e19.2)

0.65 (0.41e0.89)
90.8 (87.3e93.6)

99.1 (97.4e99.8)
457 Black 8.7 with missing scores could reduce gener- 513

40 (5.27e85.3)
458 alizability of our findings, and may not 514
Hispanic 18.2

MOEWS F
459 precisely reflect real functioning 515
Asian 4.7 MOEWS, which can only perform as
460 516
461 Other 19.6 well as the clinical variables that are 517
462 used to generate scores.19 The exclusion 518
Gestational age at delivery, %
463 of patients should not affect the com- 519

0.68 (0.44e0.92)
<24 wk 1.9

96.9 (94.6e98.5)
15.4 (1.92e45.4)
99.1 (97.5e99.8)
464 parison of the different systems, 520

40 (5.27e85.3)

AUROC, area under receiver-operating characteristic curve; CI, confidence interval; MEWS, modified early warning system; MOEWS, modified obstetric early warning scoring systems.
465 24e31 wk 1.6 however. 521
Another limitation of this study is that

MOEWS E
466 32e36 wk 3.5 522
467 the analyzed data set does not comprise 523
37e40 wk 72.6
468 all vital sign parameters for each 524
>41 wk 20.0 MOEWS that we tested. The observa-
469 525
470 Route of delivery, % tions were originally collected for the 526

5.08 (1.06e14.1)

0.72 (0.48e0.96)
99.3 (97.7e99.9)
471 analysis of the standard MEWS and, 527

84.4 (80.2e88)
60 (14.7e94.7)
Spontaneous vaginal 46.0
472 therefore, include the variables that 528
Operative vaginal 17.4

MOEWS D
473 contribute to this score only. Oxygen 529
474 Cesarean 36.3 saturation data were not included in the 530
475 Dilatation and evacuation 0.2 data set but this variable contributes to 531
476 each of the obstetric scoring systems that 532
GBS status, % we analyzed in this study. Historically,
477 533

1.42 (0.46e3.29)

0.52 (0.51e0.53)
oxygen saturation assessment has not

3.6 (1.94e6.11)
Negative 70.7
478 534
100 (47.8e100)

100 (75.3e100)
479 Positive 20.9 been considered a routine part of vital 535
triggers, compared to standard modified early warning system

sign observations in standard ward en-

MOEWS C

480 Unknown 7.4 536

481 vironments, and has therefore been 537
Comorbidiites omitted from many general early warn-
482 538
483 None 89.6 ing systems.20 The obstetric population 539
in general represents a younger cohort

Edwards. Power of MOEWS for predicting severe sepsis. Am J Obstet Gynecol 2015.
484 Diabetes mellitus 3.0 540
485 with relatively few comorbidities for 0.52 (0.51e0.53)
541
1.43 (0.47e3.3)
3.9 (2.15e6.46)

Endocrine 3.0 whom oxygen desaturation is likely to be

100 (47.8e100)

100 (76.8e100)

486 542
487 Pulmonary 2.3 a very late sign of critical illness. Oxygen 543
MOEWS B

488 Cardiovascular 1.4 saturation has been shown to be the 544

489 least likely variable to reach MOEWS 545
Neurologic 0.3
490 trigger thresholds in obstetric patients.13 546
Gastrointestinal 0.2 Furthermore in obstetric sepsis oxygen
491 547
492 Genitourinary 0.1 saturation does not predict disease 548
1.92 (0.63e4.43)

0.65 (0.62e0.67)

493 Infectious 0.1 severity.21 Some MOEWS also include 549

100 (47.8e100)

100 (96.5e100)
29 (24.3e34)

494 subjective criteria such as well/unwell or 550

Cancer 0.1
odor of liquor. These subjective in-
MOEWS A

495 551
496
Edwards. Power of MOEWS for predicting severe dicators of well-being are difficult 552
sepsis. Am J Obstet Gynecol 2015.
497 to analyze in a standardized way, and in 553
498 line with previous validation studies of 554
499 other early warning systems they were 555
not included in our analysis.18 Never-
Specificity
Sensitivity

always complete. This is a limitation re-

TABLE 3

500 556
AUROC
% (CI)

501 ported in many retrospective analyses of theless, even without these missing 557
NPV
PPV

502 early warning systems using clinical variables, all systems suffered from 558
data.15,18 Unlike other studies that have overidentification of women at risk for

MONTH 2015 American Journal of Obstetrics & Gynecology 1.e5

FLA 5.2.0 DTD
YMOB10127_proof
17 November 2014
11:58 pm
ce
 Research Obstetrics ajog.org

559 615
560 Our findings in relation to other work general early warning systems applied 616
FIGURE 1 to the obstetric population is not sur-
561 We have examined the use of MOEWS in 617
TITLE prising, the fact that MOEWS do not
562 women with infection. Sepsis is the 618
web 4C=FPO

563 leading direct cause of maternal death in reliably predict outcomes is problematic. 619
564 the United Kingdom,8 and it is respon- In the current analysis, MOEWS did 620
565 sible for serious maternal mortality and not outperform the standard MEWS 621
566 morbidity worldwide.1 Early warning when compared directly in the same 622
567 systems have been especially advocated population. Our data showed that the 623
568 for use in predicting deterioration in range of sensitivities of the 4 tested 624
569 sepsis.22 Confidential enquiries into MOEWS went as low as 40%, compared 625
570 maternal death in the United Kingdom with 100% for the MEWS. And the 626
571 have described several cases with missed lowest specificity was just 3.9%, 627
572 opportunities for early intervention in compared to 90.4% for MEWS. More- 628
573 Receiver-operating characteristic (ROC) curves women presenting with rapidly deterio- over, the MEWS achieved both high 629
574 Q8 for modified obstetric early warning systems rating sepsis.8,9 sensitivity (100%) and specificity 630
575 (MOEWS) A-F for outcome of severe sepsis. We were specifically interested in (90.4%) whereas the highest specificity 631
576 Edwards. Power of MOEWS for predicting severe sepsis. Am J predicting severe sepsis requiring critical of 96% in the MOEWS that we tested 632
577
Obstet Gynecol 2015. care. Previous research demonstrates was associated with a sensitivity of only 633
578 that early warning systems validated for 40%. The best performing MOEWS 634
deterioration, and the addition of these the nonobstetric population do not (MOEWS D) had an AUROC of 0.72,
579 635
variables could only have exacerbated reliably predict outcomes in obstetric which suggests the test has only moder-
580 636
581
this tendency. sepsis.7 While the poor performance of ate discriminatory power, and the 637
582 AUROC for MOEWS B and C suggests 638
583 that these systems are little better than 639
FIGURE 2 chance at predicting poor outcome in
584 TITLE 640
585 sepsis. Even though it had the best 641
web 4C=FPO

586 AUROC profile, MOEWS D failed to 642

587 identify 2 (40%) of the 5 women who 643
588 developed severe sepsis. It is unclear why 644
589 MEWS should perform better than the 645
590 scoring systems modified for use in 646
591 maternity. It is possible, however, that 647
592 modifications of thresholds in MOEWS 648
593 used to enhance diagnostic power for 649
594 other general obstetric conditions such 650
595 as hypertension might have reduced the 651
596 predictive power of the systems in this 652
597 cohort of women with chorioamnionitis. 653
598 The maternity population represents 654
599 a more challenging target group for 655
600 whom to develop efficient screening 656
601 tools. Pregnant women have altered 657
602 physiology secondary to pregnancy ad- 658
603 aptation, increased physiological reserve 659
604 before decompensating because of 660
605 youth, lower rates of severe deteriora- 661
606 tion, and are subject to pregnancy- 662
607 specific medical disorders. Potentially, 663
608 all of these factors challenge the ability 664
609 of screening tools to distinguish accu- 665
610 rately between sick and well pregnant 666
611 Modified obstetric early warning systems (MOEWS) distribution of highest scores for women with women, increasing the importance of 667
612 chorioamnionitis. A-C in red demonstrate distribution of scores in relation to trigger score for color- formal testing of systems used in this 668
613 coded MOEWS and D-F in blue for aggregate scoring systems. population. Despite the fact that obstet- 669
614 Edwards. Power of MOEWS for predicting severe sepsis. Am J Obstet Gynecol 2015. ric early warning systems have been 670
recommended for almost a decade,8-10

1.e6 American Journal of Obstetrics & Gynecology MONTH 2015

FLA 5.2.0 DTD
YMOB10127_proof
17 November 2014
11:58 pm
ce
 ajog.org Obstetrics Research
671 727
672 there has so far been little effort to vali- systems and staff, and unnecessary anx- statistically accurate tool.20 Surely, the 728
673 date their use or achieve consensus on iety for patients. However, MOEWS that ideal should be to identify the best tool 729
674 which is the best system.13,15 have a high false-negative rate could lead before implementation. Our analysis 730
675 Few validation studies of specific ob- to devastating clinical consequences.13 supports that view. 731
676 stetric early warning systems have been The most appropriate design of the Although a careful balance should 732
677 performed. Only one of the MOEWS MOEWS also requires consideration. We be sought, it seems logical to lean to- 733
678 in our study has been previously vali- have analyzed simple color-coded sys- wards a cautious system that minimizes 734
679 dated; MOEWS C was analyzed by Singh tems (A-C), and more complex aggre- the risk of missed opportunities for 735
680 et al13 using data from general obstetric gate scoring systems (D-E), which early intervention. Such a system would 736
681 patients, and included morbidity as involve several graded levels of clinical benefit from a simple secondary test that 737
682 well as mortality as the primary outcome response. In this data set the simpler identifies women truly at risk of severe 738
683 of interest. In that study 30% of the color-coded systems were highly sensi- sepsis, and thereby limit unnecessary 739
684 observed general obstetric population tive and all patients with the primary intervention, much the same as exists 740
685 reached MOEWS trigger levels, and outcome were highlighted. However, with electronic fetal heart rate moni- 741
686 39% of those women developed signifi- such a high proportion of women met toring and fetal scalp pH testing. 742
687 cant morbidity.13 In our population trigger criteria, that the specificity and Recently an obstetric scoring system 743
688 with chorioamnionitis, 96.4% of women positive predictive values were very poor. designed specifically for sepsis (sepsis 744
689 reached trigger thresholds defined in This reflects the simple design of the in obstetrics score, Albright et al21) 745
690 this MOEWS (C) with only 1.4% of systems, with only 2 levels of alert. has been developed. This score in- 746
691 these developing severe sepsis. However, The more complex systems C and D corporates vital signs as well as labora- 747
692 in their study Singh et al13 included cases failed to identify almost half of the tory tests (white cell count and serum 748
693 with less severe morbidity. For example, women with poor outcomes, although lactate) and is intended for triage use in 749
694 the definition of maternal morbidity their positive predictive values are the emergency department. Addition of 750
695 associated with infection was “a clinical higher. We used the highest level of alert the secondary tests to the vital sign 751
696 focus of infection  positive laboratory as the threshold for analysis in this study scoring alone was associated with much 752
697 culture, treated with antibiotics.” as we considered this level of response improved predictive power than was 753
698 Recently Carle et al15 derived a com- necessary for the severe sepsis cases. seen in the MOEWS investigated in 754
699 posite obstetric early warning score When we repeated the analysis using the our study (AUROC 0.97).21 However, 755
700 system (MOEWS F) using a large data- medium-risk threshold triggers for further work is required to develop 756
701 base of vital signs for women with MOEWS D to F, which should also similar tools for use in broader settings. 757
702 serious obstetric morbidity in a critical trigger senior medical response, the These 6 MOEWS used in current 758
703 care setting. This study uses statistical sensitivity of the MOEWS increased clinical practice vary widely in terms 759
704 analysis of the database to develop and slightly, but the specificity was also of thresholds, format, and predictive 760
705 validate a scoring system based on the reduced such that the AUROC of these power. Most MOEWS have not been 761
706 underlying principle of maximizing aggregate scoring MOEWS did not validated and performed poorly in pre- 762
707 both sensitivity and specificity. In this improve. dicting severe sepsis in obstetric patients. 763
708 highly selected obstetric population the Irrespective of the debate regarding However, simple MOEWS with high 764
709 MOEWS seems to accurately predict their design and the pragmatic levels sensitivity that are followed with con- 765
710 mortality (AUROC 0.995).15 However, of sensitivity and specificity for obstetric firmatory secondary tests are likely to be 766
711 the ability of this specific tool to predict screening systems, the fact that the the best way forward. More work is 767
712 morbidity as well as mortality in a gen- MOEWS we tested vary so widely in required to further develop and validate 768
713 eral obstetric population has yet to be terms of sensitivity and specificity is early warning systems for use in this 769
714 determined. In our general maternity important in itself. It is very likely that setting, with the ultimate aim to produce 770
715 population with chorioamnionitis the many more locally adapted variations of an effective standardized system that 771
716 discriminatory power of this scoring these tools are used in clinical prac- can be implemented throughout mater- 772
717 system was much lower (AUROC 0.637). tice.12,13,20 Our data demonstrate that nity care. -
773
718 As well as undertaking validation some MOEWS perform much better 774
719 studies, there needs to be a debate as to than others. It has been suggested that 775
720 appropriate levels of predictive power. standardization of early warning systems REFERENCES
776
721 There is usually a tradeoff between would provide the opportunity for 1. Acosta CD, Knight M. Sepsis and maternal 777
722 sensitivity and specificity. MOEWS were improving communication, reducing mortality. Curr Opin Obstet Gynecol 2013;25:
778
designed as simple bedside screening variation in care, and standardizing 109-16.
723 2. Rangel-Frausto MS, Pittet D, Costigan M, 779
724 tools for identifying women at risk of staff training from an undergraduate 780
Hwang T, Davis CS, Wenzel RP. The natural
725 serious morbidity. Systems that generate level, and that this strategy may be history of the systemic inflammatory response 781
726 a large number of false positives might more beneficial for effecting change in syndrome (SIRS): a prospective study. JAMA 782
create an excessive burden on health patient outcomes than defining the most 1995;273:117-23.

MONTH 2015 American Journal of Obstetrics & Gynecology 1.e7

FLA 5.2.0 DTD
YMOB10127_proof
17 November 2014
11:58 pm
ce
 Research Obstetrics ajog.org

783 839
3. van Dillen J, Zwart J, Schutte J, van 10. Lewis G, ed. Why mothers die 2000-2002. Center Case Mix Program database. Anaes-
784 Roosmalen J. Maternal sepsis: epidemiology, The sixth report of the confidential enquiries thesia 2013;68:354-67. 840
785 etiology and outcome. Curr Opin Infect Dis into maternal deaths in the United Kingdom. 16. Levy MM, Fink MP, Marshall JC, et al. 2001 841
786 2010;23:249-54. RCOG Press. 2004:1-350. Available at: http:// SCCM/ESICM/ACCP/ATS/SIS international 842
787 4. Lucas DN, Robinson PN, Nel MR. Sepsis in www.hqip.org.uk/assets/NCAPOP-Library/ sepsis definitions conference. Crit Care Med 843
obstetrics and the role of the anesthetist. Int J CMACE-Reports/33.-2004-Why-Mothers-Die- 2003;31:1250-6.
788 844
Obstet Anesth 2012;21:56-67. 2000-2002-The-Sixth-Report-of-the-Confiden- 17. Tita ATN, Andrews WW. Diagnosis and
789 5. Subbe CP, Kruger M, Rutherford P, tial-Enquiries-into-Maternal-Deaths-in-the-UK. management of clinical chorioamnionitis. Clin 845
790 Gemmel L. Validation of a modified early warning pdf. Accessed DATE. Perinatol 2010;37:339-54. 846
791 score in medical admissions. QJM 2001;94: 11. Winter C, Crofts J, Laxton C, Barnfield S, 18. Smith GB, Prytherch DR, Schmidt PE, 847
792 521-6. Draycott T, eds. PROMPT course manual, 2nd Featherstone PI, Higgins B. A review, and per- 848
6. Kho A, Rotz D, Alrahi K, et al. Utility ed. RCOG Press; 2012. formance evaluation, of single-parameter “track Q6
793 849
of commonly captured data from an EHR to 12. Swanton RDJ, Al-Rawi S, Wee MYK. and trigger” systems. Resuscitation 2008;79:
794 identify hospitalized patients at risk for clinical A national survey of obstetric early warning 11-21. 850
795 deterioration. AMIA Annu Symp Proc 2007: systems in the United Kingdom. Int J Obstet 19. Gao H, McDonnell A, Harrison DA, et al. 851
796 404-8. Anesth 2009;18:253-7. Systematic review and evaluation of physiolog- 852
797 7. Lappen JR, Keene M, Lore M, Grobman WA, 13. Singh S, McGlennan A, England A, ical track and trigger warning systems for iden- 853
Gossett DR. Existing models fail to predict Simons R. A validation study of the CEMACH tifying at-risk patients on the ward. Intensive
798 854
sepsis in an obstetric population with intrauter- recommended modified early obstetric warning Care Med 2007;33:667-79.
799 ine infection. Am J Obstet Gynecol 2010;203: system (MEOWS). Anaesthesia 2011;67:12-8. 20. Royal College of Physicians. National early 855
800 573.e1-5. 14. Maternal Critical Care Working Group. warning score (NEWS): standardizing the 856
801 8. Cantwell R, Clutton-Brock T, Cooper G, et al. Providing equity of critical and maternity care for assessment of acute-illness severity in the NHS; 857
802 Saving mothers’ livesereviewing maternal the critically ill pregnant or recently pregnant report of a working party. London: RCP; 2012. 858
deaths to make motherhood safer: 2006-2008. woman. (Royal College of Anesthetists, RCM, Ob- 21. Albright CM, Ali TN, Lopes V, Rouse D,
803 859
The eighth report of the confidential enquiries stetric Anesthetists Association, BMFMS, RCOG, Anderson BL. The sepsis in obstetrics score: a
804 into maternal deaths in the United Kingdom. Intensive Care Society, eds). 2011:1-58. Available model to identify risk of morbidity from sepsis. 860
805 Q5 BJOG 2011;118(Suppl):1-203. at: http://www.rcog.org.uk/files/rcog-corp/Prov_ Am J Obstet Gynecol 2014;211:39.e1-8. 861
806 9. Lewis G, ed. Saving mothers’ livesereviewing Eq_MatandCritCare.pdf. Accessed DATE. 22. Fullerton JN, Price CL, Silvey NE, Brace SJ, Q7 862
807 maternal deaths to make motherhood safer: 15. Carle C, Alexander P, Columb M, Johal J. Perkins GD. Is the modified early warning score 863
2003-2005. The seventh report on confidential Design and internal validation of an obstetric (MEWS) superior to clinician judgment in
808 864
enquiries into maternal deaths in the United early warning score: secondary analysis of the detecting critical illness in the pre-hospital envi-
809 Kingdom. London: CEMACH; 2007:1-296. Intensive Care National Audit and Research ronment? Resuscitation 2012;83:557-62. 865
810 866
811 867
812 868
813 869
814 870
815 871
816 872
817 873
818 874
819 875
820 876
821 877
822 878
823 879
824 880
825 881
826 882
827 883
828 884
829 885
830 886
831 887
832 888
833 889
834 890
835 891
836 892
837 893
838 894

1.e8 American Journal of Obstetrics & Gynecology MONTH 2015

FLA 5.2.0 DTD
YMOB10127_proof
17 November 2014
11:58 pm
ce