title: Modified obstetric early warning scoring systems (MOEWS): validating the diagnostic performance for severe sepsis in women with chorioamnionitis.
abstract: OBJECTIVE
  We sought to compare the predictive power of published modified obstetric early warning scoring systems (MOEWS) for the development of severe sepsis in women with chorioamnionitis.
  
  
  METHODS
  This was a retrospective cohort study using prospectively collected clinical observations at a single tertiary unit (Chicago, IL). Hospital databases and patient records were searched to identify and verify cases with clinically diagnosed chorioamnionitis during the study period (June 2006 through November 2007). Vital sign data (heart rate, respiratory rate, blood pressure, temperature, mental state) for these cases were extracted from an electronic database and the single worst composite recording was identified for analysis. Global literature databases were searched (2014) to identify examples of MOEWS. Scores for each identified MOEWS were derived from each set of vital sign recordings during the presentation with chorioamnionitis. The performance of these MOEWS (the primary outcome) was then analyzed and compared using their sensitivity, specificity, positive and negative predictive values, and receiver-operating characteristic curve for severe sepsis.
  
  
  RESULTS
  Six MOEWS were identified. There was wide variation in design and pathophysiological thresholds used for clinical alerts. In all, 913 women with chorioamnionitis were identified from the clinical database. In all, 364 cases with complete data for all physiological indicators were included in analysis. Five women developed severe sepsis, including 1 woman who died. The sensitivities of the MOEWS in predicting the severe deterioration ranged from 40-100% and the specificities varied even more ranging from 4-97%. The positive predictive values were low for all MOEWS ranging from <2-15%. The MOEWS with simpler designs tended to be more sensitive, whereas the more complex MOEWS were more specific, but failed to identify some of the women who developed severe sepsis.
  
  
  CONCLUSIONS
  Currently used MOEWS vary widely in terms of alert thresholds, format, and accuracy. Most MOEWS have not been validated. The MOEWS generally performed poorly in predicting severe sepsis in obstetric patients; in general severe sepsis was overdetected. Simple MOEWS with high sensitivity followed with more specific secondary testing is likely to be the best way forward. Further research is required to develop early warning systems for use in this setting.
authors.affiliation: School of Clinical Sciences, University of Bristol, Bristol, United Kingdom. Electronic address: sian.edwards@doctors.org.uk.
authors.forename: Sian E
authors.initials: SE
authors.lastname: Edwards
authors.affiliation: Feinberg School of Medicine, Northwestern University, Chicago, IL.
authors.forename: William A
authors.initials: WA
authors.lastname: Grobman
authors.affiliation: MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH.
authors.forename: Justin R
authors.initials: JR
authors.lastname: Lappen
authors.affiliation: Research into Safety and Quality (RISQ), Southmead Hospital, Bristol, United Kingdom.
authors.forename: Cathy
authors.initials: C
authors.lastname: Winter
authors.affiliation: Research into Safety and Quality (RISQ), Southmead Hospital, United Kingdom.
authors.forename: Robert
authors.initials: R
authors.lastname: Fox
authors.affiliation: School of Clinical Sciences, University of Bristol, Bristol, United Kingdom.
authors.forename: Erik
authors.initials: E
authors.lastname: Lenguerrand
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom.
authors.forename: Timothy
authors.initials: T
authors.lastname: Draycott
mesh_terms: D000328:Adult; D002821:Chorioamnionitis / Q000503:physiopathology*; D015331:Cohort Studies; D042241:Early Diagnosis; D005260:Female; D006801:Humans; D011237:Predictive Value of Tests; D011247:Pregnancy; D012372:ROC Curve; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D018805:Sepsis / Q000175:diagnosis* / Q000209:etiology; D012720:Severity of Illness Index
keywords: chorioamnionitis; early warning systems; patient safety; sepsis