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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
identication 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 denes a near-miss as a woman who
nearly died but survived a complication that occurredduring
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 20092010.3
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 near-
misses.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
1Obstetrics and Gynaecology Clinical Care Unit,
King Edward Memorial Hospital, Perth,
Western Australia, Australia2
Obstetrics and Gynaecology, School of Medicine,
James Cook University, Cairns, Queensland, Australia
E-mail: [email protected]
DOI: 10.1111/ajo.12314
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 Gynaecol2014; 54: 445449.
2 Say L, Souza JP, Pattinson R, for the WHO working group on
Maternal Mortality classications. Maternal near-miss
towards a standard tool for monitoring quality of maternal
health care. Best Pract Res Clin Obstet Gynaecol2009; 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: 421425.
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/reproduc-
tivehealth/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 patients 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 specic 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 inuence 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 elds to be collected and the
funding mechanism for such an endeavour. Given this
area of practice represents the intersection betweenintensive
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 inuenza in the pregnant and
post-partum population in 2009.4
196 2015 The Royal Australian and New Zealand College of
Obstetricians and Gynaecologists
Letters to the Editor
Te Australian andNew Zealand Journalof Obstetrics and
Gynaecology
http://www/http://www/http://www/http://www/
7/25/2019 18-ajo12354
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Joanne L. PAXTON1,2
, Jeffrey PRESNEILL3
and
Leanne AITKEN4
1School of Nursing and Midwifery, Grifth 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, Grifth Health Institute, Grifth University
&Princess Alexandra Hospital, Brisbane, Queensland,
Australia
E-mail: [email protected]
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 Gynaecol2014; 54: 445449.
2 Sultan P, Arulkumaran N, Rhodes A. Provision of critical
care
services for the obstetric population. Best Pract Res Clin
Obstet
Gynaecol2013; 27: 803809.
3 Independent Hospital Pricing Authority. Pricing Framework
for
Australian Public Hospital Services 2014-15. http://www ihpa
gov a u/internet/ihpa/publishing
nsf/Content/pricingframework-
public-hospitals-2014-15 htm [Accessed 23 December 2014].
4 The ANZIC Inuenza Investigators and Australasian Maternity
Outcomes Surveillance System. Critical illness due to 2009
A/H1N1 inuenza in pregnant and postpartum women:
population based cohort study. BMJ2010; 340: c1279.
2015 The Royal Australian and New Zealand College of
Obstetricians and Gynaecologists 197
Letters to the Editor
http://www/http://www/
