Predicción de desenlaces maternos adversos en pacientes obstétricas con infección mediante el índice de choque diastólico
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Fecha
2025
Autores
Córdoba Torres, Genesis Jhoanna
Arias Ibarra, Kenny Yurexi
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Ediciones Universidad Simón Bolívar
Facultad de Ciencias de la Salud
Facultad de Ciencias de la Salud
Resumen
Introducción: La sepsis obstétrica constituye una causa significativa de mortalidad
materna global (10.7%), ocupando el tercer lugar en Colombia (2023). Las
herramientas diagnósticas actuales muestran limitaciones en población obstétrica
debido a los cambios fisiológicos del embarazo que pueden enmascarar signos
tempranos de deterioro. El estudio evaluó el valor predictivo del Índice de Choque
e Índice de Choque Diastólico para predecir desenlaces maternos adversos en
pacientes obstétricas con infección, basándose en investigaciones previas que
demostraron su utilidad en población general. Metodología: Estudio analítico
observacional de cohorte retrospectivo mediante análisis secundario de la base de
datos COLLOSSAL, incluyendo 2198 mujeres embarazadas o puérperas (≤42 días)
entre 14-49 años con diagnóstico de infección atendidas en 12 instituciones
colombianas (2018-2022). Se calcularon y analizaron los índices de choque e índice
de choque diastólico, junto con variables sociodemográficas, clínicas y paraclínicas.
El desenlace primario fueron los desenlaces maternos adversos (ingreso a la unidad
de cuidados intensivos, uso de vasopresores o ventilación mecánica invasiva) y los
secundarios incluyeron desenlaces neonatales adversos. Se realizó análisis de
componentes principales para controlar la multicolinealidad entre con estratificación
por terciles y regresión logística multivariada. Resultados: Se identificó una
correlación moderadamente fuerte entre índice de choque e índice de choque
diastólico (R=0.7314, p<0.001), con el primer componente principal explicando
53.5% de la varianza total. Las pacientes del tercil superior (T3) presentaron edad
significativamente menor (22 vs 24 años, p<0.001), mayor frecuencia cardíaca (108
vs 82 vs 78 lpm, p<0.001) y leucocitosis más marcada (14.1 vs 11.47 x10³/mm³,
p<0.001), mientras que el peso e índice de masa corporal fueron mayores en el tercil
inferior. Los desenlaces maternos adversos fueron significativamente más
frecuentes en T3 (12% vs 4.1% y 4.2%, p<0.001). El análisis de regresión logística
identificó al primer componente principal como predictor significativo (OR ajustado
1.68, IC 95% 1.51-1.87, p<0.001), con T3 representando un riesgo significativo (OR
ajustado 3.16, IC 95% 2.22-4.48, p<0.001), mientras T1 y T2 actuaron como
factores protectores (reducción del 53% y 48% respectivamente). Respecto a los
desenlaces neonatales adversos, se observó una tendencia paradójica no
significativa a menor proporción de eventos en T3 (36.7% vs 55.6% en T1, p=0.092).
Conclusiones: El análisis por terciles del índice de choque e índice de choque
diastólico proporciona una estratificación útil del riesgo para identificar pacientes
obstétricas con infección en riesgo de desarrollar desenlaces maternos adversos.
Hallazgos como la edad más joven en pacientes de mayor riesgo contradicen
perfiles tradicionales de riesgo obstétrico, sugiriendo que estos índices capturan
aspectos de la respuesta hemodinámica a la infección no reflejados en factores
convencionales. La simplicidad de cálculo del índice de choque e índice de choque
diastólico facilita su implementación incluso en entornos con recursos limitados,
representando una herramienta potencialmente valiosa para mejorar el triaje y la
atención temprana en pacientes obstétricas con sospecha de infección,
contribuyendo potencialmente a reducir la morbimortalidad materna asociada a
sepsis
Introduction: Obstetric sepsis represents a significant cause of global maternal mortality (10.7%), ranking third in Colombia (2023). Current diagnostic tools show limitations in the obstetric population due to pregnancy-related physiological changes that may mask early signs of deterioration. This study evaluated the predictive value of the Shock Index and Diastolic Shock Index for adverse maternal outcomes in obstetric patients with infection, based on previous research demonstrating their utility in the general population. Methodology: Retrospective observational cohort study through secondary analysis of the COLLOSSAL database, including 2198 pregnant or postpartum women (≤42 days) aged 14-49 years with diagnosed infection treated in 12 Colombian institutions (2018-2022). Shock Index and Diastolic Shock Index were calculated and analyzed alongside sociodemographic, clinical, and paraclinical variables. The primary outcome was adverse maternal outcomes (the intensive care unit admission, vasopressor use, or invasive mechanical ventilation), and secondary outcomes included adverse neonatal outcomes. Principal component analysis was performed to control for multicollinearity between SI and DSI, with tertile stratification and multivariate logistic regression. Results: A moderately strong correlation between Shock Index and Diastolic Shock Index was identified (R=0.7314, p<0.001), with the first principal component explaining 53.5% of the total variance. Patients in the upper tertile (T3) had significantly lower age (22 vs. 24 years, p<0.001), higher heart rate (108 vs. 82 vs. 78 bpm, p<0.001), and more pronounced leukocytosis (14.1 vs. 11.47 x10³/mm³, p<0.001), while weight and BMI were higher in the lower tertile. Adverse maternal outcomes were significantly more frequent in T3 (12% vs. 4.1% and 4.2%, p<0.001). Logistic regression analysis identified the first principal component as a significant predictor (adjusted OR 1.68, 95% CI 1.51-1.87, p<0.001), with T3 representing a significant risk (adjusted OR 3.16, 95% CI 2.22-4.48, p<0.001), while T1 and T2 acted as protective factors (reduction of 53% and 48%, respectively). Regarding adverse neonatal outcomes, a non-significant paradoxical trend toward a lower proportion of events in T3 was observed (36.7% vs. 55.6% in T1, p=0.092). Discussion and Conclusions: Tertile analysis of Shock Index and Diastolic Shock Index provides useful risk stratification to identify obstetric patients with infection at risk of developing adverse maternal outcomes. Findings such as younger age in higher-risk patients contradict traditional obstetric risk profiles, suggesting that these indices capture aspects of the hemodynamic response to infection not reflected in conventional factors. The simplicity of calculating Shock Index and Diastolic Shock Index facilitates their implementation even in resource-limited settings, representing a potentially valuable tool to improve triage and early care in obstetric patients with suspected infection, potentially contributing to reducing maternal morbidity and mortality associated with sepsis.
Introduction: Obstetric sepsis represents a significant cause of global maternal mortality (10.7%), ranking third in Colombia (2023). Current diagnostic tools show limitations in the obstetric population due to pregnancy-related physiological changes that may mask early signs of deterioration. This study evaluated the predictive value of the Shock Index and Diastolic Shock Index for adverse maternal outcomes in obstetric patients with infection, based on previous research demonstrating their utility in the general population. Methodology: Retrospective observational cohort study through secondary analysis of the COLLOSSAL database, including 2198 pregnant or postpartum women (≤42 days) aged 14-49 years with diagnosed infection treated in 12 Colombian institutions (2018-2022). Shock Index and Diastolic Shock Index were calculated and analyzed alongside sociodemographic, clinical, and paraclinical variables. The primary outcome was adverse maternal outcomes (the intensive care unit admission, vasopressor use, or invasive mechanical ventilation), and secondary outcomes included adverse neonatal outcomes. Principal component analysis was performed to control for multicollinearity between SI and DSI, with tertile stratification and multivariate logistic regression. Results: A moderately strong correlation between Shock Index and Diastolic Shock Index was identified (R=0.7314, p<0.001), with the first principal component explaining 53.5% of the total variance. Patients in the upper tertile (T3) had significantly lower age (22 vs. 24 years, p<0.001), higher heart rate (108 vs. 82 vs. 78 bpm, p<0.001), and more pronounced leukocytosis (14.1 vs. 11.47 x10³/mm³, p<0.001), while weight and BMI were higher in the lower tertile. Adverse maternal outcomes were significantly more frequent in T3 (12% vs. 4.1% and 4.2%, p<0.001). Logistic regression analysis identified the first principal component as a significant predictor (adjusted OR 1.68, 95% CI 1.51-1.87, p<0.001), with T3 representing a significant risk (adjusted OR 3.16, 95% CI 2.22-4.48, p<0.001), while T1 and T2 acted as protective factors (reduction of 53% and 48%, respectively). Regarding adverse neonatal outcomes, a non-significant paradoxical trend toward a lower proportion of events in T3 was observed (36.7% vs. 55.6% in T1, p=0.092). Discussion and Conclusions: Tertile analysis of Shock Index and Diastolic Shock Index provides useful risk stratification to identify obstetric patients with infection at risk of developing adverse maternal outcomes. Findings such as younger age in higher-risk patients contradict traditional obstetric risk profiles, suggesting that these indices capture aspects of the hemodynamic response to infection not reflected in conventional factors. The simplicity of calculating Shock Index and Diastolic Shock Index facilitates their implementation even in resource-limited settings, representing a potentially valuable tool to improve triage and early care in obstetric patients with suspected infection, potentially contributing to reducing maternal morbidity and mortality associated with sepsis.
Descripción
Palabras clave
Infección, Índice de choque, Índice de choque diastólico, Desenlaces maternos adversos, Desenlaces neonatales adversos
