Letters to the Editor

should not be completely discarded as a marker for severe morbidity, but rather should be examined in the context of the underlying illness and pathology. The World Health Organization (WHO) proposed for identification of maternal near-miss in 2009 uses a combination of criteria to identify these cases: clinical, interventional (including ICU admission), and laboratory based.2 WHO defines a near-miss as “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy”. We suggest that in the developed world it is more appropriate to consider a combination of criteria as proposed by the WHO and include ICU admission with at least one other indicator of severe morbidity such as the need for peripartum hysterectomy or more than 5U of blood transfusion. We found this system workable in the setting of a large regional hospital in North Queensland in 2009–2010.3 On the other hand, in developing countries ICU admission can be a very useful marker of severe maternal morbidity; in a recent review of maternal morbidity at Port Moresby General Hospital, 70% of maternal near-miss cases should expect to require ICU intervention.4 However, in many under-resourced countries, the lack of ICU beds means that many women for whom intense monitoring and intervention would be indicated are never admitted; here also ICU admission needs to be combined with clinical and laboratory-based criteria to identify nearmisses. The WHO criteria are designed to enable individual units to assess and compare their severe maternal morbidity management and outcomes, and thus differ from the surveillance strategies of bodies such as AMOSS and UKOSS, which deal with national trends and rare events, although the two approaches can be complementary. We are continuing to research the application of the WHO criteria in several other Australasian hospitals and hope that others will do the same. Skandarupan JAYARATNAM1 and Caroline de COSTA2 1 Obstetrics and Gynaecology Clinical Care Unit, King Edward Memorial Hospital, Perth, Western Australia, Australia 2 Obstetrics and Gynaecology, School of Medicine, James Cook University, Cairns, Queensland, Australia E-mail: [email protected] DOI: 10.1111/ajo.12314

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References 1 Paxton JL, Presneill J, Aitken L. Characteristics of obstetric patients referred to intensive care in an Australian tertiary hospital. Aust N Z J Obstet Gynaecol 2014; 54: 445–449. 2 Say L, Souza JP, Pattinson R, for the WHO working group on Maternal Mortality classifications. Maternal near-miss – towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol 2009; 23: 287– 296. 3 Jayaratnam S, de Costa C, Howat P. Developing an assessment tool for maternal morbidity ‘near-miss’ – a prospective study in a large Australian regional hospital. Aust N Z J Obstet Gynaecol 2011; 51: 421–425. 4 World Health Organization (WHO). Evaluating the quality of care for severe pregnancy complications – The WHO near-miss approach for maternal health, 2011. [Accessed 28 November, 2014]. Available from URL: http://www.who.int/reproductivehealth/en

Re: Characteristics of obstetric patients referred to intensive care in an Australian tertiary hospital We fully agree with these authors that the fact of an intensive care unit (ICU) admission for an obstetric patient1 is a potentially useful but also confounded marker for severe obstetric morbidity. The receipt of treatment in an ICU by an obstetric patient should be interpreted in the context of the patient’s clinical comorbidities, the modalities of critical care support provided and the characteristics of the health system in the relevant country. We also agree that the absence of a specific obstetric high-dependency unit (HDU) on our campus likely contributed to the relatively high-admission rate of the obstetric cohort to our general adult ICU. There is evidence that specialist obstetric HDUs may be associated with safe care with a lower rate of patient transfer to ICU.2 The absence of an Australian national funding model for HDUs may influence the practices that we reported.3 We strongly support the need for a binational Australian and New Zealand collection of World Health Organization criteria and other relevant data to fully characterise obstetric critical care in our region. The challenge is to reach agreement on the data fields to be collected and the funding mechanism for such an endeavour. Given this area of practice represents the intersection between intensive care and obstetrics, it may be useful to build on the experience of a collaboration between The Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD) and the Australasian Maternity Outcomes Surveillance System (AMOSS) which characterised the effects of influenza in the pregnant and post-partum population in 2009.4

© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology

Letters to the Editor

Joanne L. PAXTON1,2, Jeffrey PRESNEILL3 and Leanne AITKEN4 1 School of Nursing and Midwifery, Griffith University, Brisbane, 2 Gold Coast University Hospital, Gold Coast, 3 Intensive Care Physician, Mater Adult Hospital, University of Queensland and Monash University, 4 School of Nursing & Midwifery, Centre for Health Practice Innovation, Griffith Health Institute, Griffith University & Princess Alexandra Hospital, Brisbane, Queensland, Australia E-mail: [email protected]

2 Sultan P, Arulkumaran N, Rhodes A. Provision of critical care services for the obstetric population. Best Pract Res Clin Obstet Gynaecol 2013; 27: 803–809. 3 Independent Hospital Pricing Authority. Pricing Framework for Australian Public Hospital Services 2014-15. http://www ihpa gov au/internet/ihpa/publishing nsf/Content/pricingframeworkpublic-hospitals-2014-15 htm [Accessed 23 December 2014]. 4 The ANZIC Influenza Investigators and Australasian Maternity Outcomes Surveillance System. Critical illness due to 2009 A/H1N1 influenza in pregnant and postpartum women: population based cohort study. BMJ 2010; 340: c1279.

DOI: 10.1111/ajo.12354

References 1 Paxton JL, Presneill J, Aitken L. Characteristics of obstetric patients referred to intensive care in an Australian tertiary hospital. Aust N Z J Obstet Gynaecol 2014; 54: 445–449.

© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists

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Re: Characteristics of obstetric patients referred to intensive care in an Australian tertiary hospital.

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