Critical care management of the obstetric patient

Determinants of maternal mortality in a critical care unit: A prospective analysis

Introduction:

An admission of a pregnant woman to an intensive care unit (ICU) is considered as an objective marker of maternal near miss. Only a few studies from the Indian subcontinent have reported on the ability of ICU scoring systems in predicting the mortality in obstetric patients.

Methods:

A prospective analysis of all critically ill obstetric patients admitted to the critical care department was done.

Results:

In the period between April 2013 and September 2017, there were 101 obstetric admissions to the critical care ICU. Of these, 82 patients (81.2%) were discharged from the hospital, 18 patients (17.8%) died, and one left against medical advice. The common diagnoses seen in these patients were cardiac failure (n = 39; 38.6%); pregnancy-induced hypertension (n = 26; 25.7%); acute respiratory distress syndrome (n = 20; 19.8%); intra-abdominal sepsis (n = 19; 18.8%); tropical diseases (n = 19; 18.8%); and tuberculosis (n = 13; 12.9%). When we compared the survivors with the nonsurvivors, a higher severity of illness score and a low PaO₂/FiO₂ were found to increase the odds of death. The area of distribution under the receiver operator characteristic curve was 0.726 (95% confidence interval [CI] = 0.575–0.877), 0.890 (95% CI = 0.773–1.006), 0.867 (95% CI = 0.755–0.979), and 0.850 (95% CI = 0.720–0.980) for the PaO₂/FiO₂, Simplified Acute Physiology Score (SAPS) II, Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation (APACHE) II score, respectively, for predicting mortality. The standardized mortality ratio was better with SAPSII than with APACHE II.

Conclusions:

Cardiac dysfunction is a leading cause of ICU admission. Obstetric patients frequently require ventilatory support, intensive hemodynamic monitoring, and blood transfusion. The APACHE II score is a good index for assessing ICU outcomes.

A Prospective Study of Clinical Characteristics and Interventions Required in Critically Ill Obstetric Patients

Introduction

Obstetric patients are a special group of patients whose management is challenged by concerns for fetal viability, altered maternal physiology, and diseases specific to pregnancy.

Materials and methods

A prospective analysis of all obstetric patients admitted to the critical care department was done to assess reasons for transfer to the critical care unit (CCU) and the interventions required for management of these patients.

Results

Between June 2013 and September 2017, obstetric admission comprised 95 women (5.9%) of the total critical care admissions. There were 77 patients (81.1%) who were discharged from the hospital and 18 patients (18.9%) died. In most of the cases, the primary reasons for shifting the patient to the CCU were severe preeclampsia with pulmonary edema (22.1%), eclampsia (8.4%), acute respiratory distress syndrome (ARDS) (14.7%), and hypovolemic shock in antepartum hemorrhage (APH) and postpartum hemorrhage (PPH) (10.5 and 13.7%, respectively). It was seen that 73 patients (76.8%) required ventilator support, 58 patients (57.4%) required vasopressor support, and intensive hemodynamic monitoring and blood/blood products were transfused in 55 patients (54.5%). The need for ventilator support was more in patients with a lower PaO₂/FiO₂ and a higher APACHE II score. Patients with a high severity of illness score and a lower PaO₂/FiO₂ had higher odds of requiring vasopressors. Low hemoglobin at the time of transfer to the CCU and a prolonged hospital stay were found to predict the need for blood transfusion.

Conclusion

Obstetric patients are susceptible to critical illnesses but timely management improves the outcome of these young women.

How to cite this article

Suri J, Kumar R, Gupta A, Mittal P, Suri JC. A Prospective Study of Clinical Characteristics and Interventions Required in Critically Ill Obstetric Patients. Indian J Crit Care Med 2020;24(8):677–682.

A blueprint to establish a four-bed obstetric critical care unit in the labor ward of a central hospital

Patients at risk of organ dysfunction or with established organ dysfunction should be referred to central or tertiary-level hospitals. However, even in central hospitals, intensive care unit (ICU) beds are often unavailable, which may contribute to maternal deaths. One pragmatic solution is to establish obstetric critical care units (OCCUs) in the labor wards of central hospitals; however, specific guidance on how to do this is limited. In addition, globally applicable standards of care are lacking, with uncertainty regarding who should lead obstetric critical care. In this article the specific OCCU infrastructure, equipment and human resources required to establish such units in central hospitals in low- and middle-income countries are described in sufficient detail for easy replication. Admission and discharge guidelines and operational recommendations that include quality indicators are also provided.

Development and internal validation of the multivariable CIPHER (Collaborative Integrated Pregnancy High-dependency Estimate of Risk) clinical risk prediction model

Background

Intensive care unit (ICU) outcome prediction models, such as Acute Physiology And Chronic Health Evaluation (APACHE), were designed in general critical care populations and their use in obstetric populations is contentious. The aim of the CIPHER (Collaborative Integrated Pregnancy High-dependency Estimate of Risk) study was to develop and internally validate a multivariable prognostic model calibrated specifically for pregnant or recently delivered women admitted for critical care.

Methods

A retrospective observational cohort was created for this study from 13 tertiary facilities across five high-income and six low- or middle-income countries. Women admitted to an ICU for more than 24 h during pregnancy or less than 6 weeks post-partum from 2000 to 2012 were included in the cohort. A composite primary outcome was defined as maternal death or need for organ support for more than 7 days or acute life-saving intervention. Model development involved selection of candidate predictor variables based on prior evidence of effect, availability across study sites, and use of LASSO (Least Absolute Shrinkage and Selection Operator) model building after multiple imputation using chained equations to address missing data for variable selection. The final model was estimated using multivariable logistic regression. Internal validation was completed using bootstrapping to correct for optimism in model performance measures of discrimination and calibration.

Results

Overall, 127 out of 769 (16.5%) women experienced an adverse outcome. Predictors included in the final CIPHER model were maternal age, surgery in the preceding 24 h, systolic blood pressure, Glasgow Coma Scale score, serum sodium, serum potassium, activated partial thromboplastin time, arterial blood gas (ABG) pH, serum creatinine, and serum bilirubin. After internal validation, the model maintained excellent discrimination (area under the curve of the receiver operating characteristic (AUROC) 0.82, 95% confidence interval (CI) 0.81 to 0.84) and good calibration (slope of 0.92, 95% CI 0.91 to 0.92 and intercept of −0.11, 95% CI −0.13 to −0.08).

Conclusions

The CIPHER model has the potential to be a pragmatic risk prediction tool. CIPHER can identify critically ill pregnant women at highest risk for adverse outcomes, inform counseling of patients about risk, and facilitate bench-marking of outcomes between centers by adjusting for baseline risk.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2215-6) contains supplementary material, which is available to authorized users.

Practice Bulletin No. 170: Critical Care in Pregnancy

Critical care in pregnancy is a field that remains unevenly researched. Although there is a body of evidence to guide many recommendations in critical care, limited research specifically addresses obstetric critical care. The purpose of this document is to review the available evidence, propose strategies for care, and highlight the need for additional research. Much of the review will, of necessity, focus on general principles of critical care, extrapolating where possible to obstetric critical care.

Neurologic complications in critically ill pregnant patients

Neurologic complications in a critically ill pregnant woman are uncommon but some of the complications (such as eclampsia) are unique to pregnancy and the puerperal period. Other neurologic complications (such as seizures in the setting of epilepsy) may worsen during pregnancy. Clinical signs and symptoms such as seizure, headache, weakness, focal neurologic deficits, and decreased level of consciousness require careful consideration of potential causes to ensure prompt treatment measures are instituted to prevent ongoing neurologic injury. Clinicians should be familiar with syndromes such as pre-eclampsia, eclampsia, stroke, posterior reversible encephalopathy syndrome, and reversible cerebral vasoconstriction syndrome. Necessary imaging studies can usually be performed safely in pregnancy. Scoring systems for predicting maternal mortality are inadequate, as are recommendations for neurorehabilitation. Tensions can arise when there is conflict between the interests of the mother and the interests of the fetus, but in general maternal health is prioritized. The complexity of care requires a multidisciplinary and multiprofessional approach to achieve best outcome in an often unexpected situation.

The Usefulness of the APACHE II Score in Obstetric Critical Care: A Structured Review

OBJECTIVE

To assess the performance of the Acute Physiology and Chronic Health Evaluation II (APACHE II) mortality prediction model in pregnant and recently pregnant women receiving critical care in low-, middle-, and high-income countries during the study period (1985-2015), using a structured literature review.

DATA SOURCES

Ovid MEDLINE, Embase, Web of Science, and Evidence-Based Medicine Reviews, searched for articles published between 1985 and 2015.

STUDY SELECTION

Twenty-five studies (24 publications), of which two were prospective, were included in the analyses. Ten studies were from high-income countries (HICs), and 15 were from low- and middle-income countries (LMICs). Median study duration and size were six years and 124 women, respectively.

DATA SYNTHESIS

ICU admission complicates 0.48% of deliveries, and pregnant and recently pregnant women account for 1.49% of ICU admissions. One quarter were admitted while pregnant, three quarters of these for an obstetric indication and for a median of three days. The median APACHE II score was 10.9, with a median APACHE II-predicted mortality of 16.6%. Observed mortality was 4.6%, and the median standardized mortality ratio was 0.36 (interquartile range 0.23 to 0.73). The standardized mortality ratio was < 0.9 in 24 of 25 studies. Women in HICs were more frequently admitted with a medical comorbidity but were less likely to die than were women in LMICs.

CONCLUSION

The APACHE II score consistently overestimates mortality risks for pregnant and recently pregnant women receiving critical care, whether they reside in HICs or LMICs. There is a need for a pregnancy-specific outcome prediction model for these women.

Intensive care management and outcome of women with hypertensive diseases of pregnancy

INTRODUCTION

The burden of hypertensive diseases on the health care is enormous given to the high population in Sub-Saharan Africa and related disproportionate representation in global maternal mortality.

MATERIALS AND METHODS

All women with hypertensive diseases of pregnancy who got admitted into the general ICU of the University of Benin Teaching Hospital between January 2006 and December 2010 were studied. Only the records of women who completed 28 weeks of gestation and were admitted during labour and delivery or puerperium to the ICU were examined.

RESULTS

There were 13061 deliveries within the 5-year study period; 9301 by vaginal delivery and 3860 through Caesarean section. 52 (51.5%) of the obstetric patients had hypertensive diseases of pregnancy. Of 52 women with pre-eclampsia and eclampsia, 45/52 had caesarean section and 7/52 had SVD. Admission was mainly postpartum 48/52 (92.3%). 35/52 (67.3%) were transferred to the ward and 17 died (32.7%), giving the ICU maternal mortality rate of 307/1000 deliveries. 30 women developed pulmonary oedema alone or with renal impairment; 14 women were transferred and 16 died while 21 other patients who had renal impairment alone, HELLP, sepsis, etc were transferred out. There was about a 12-fold risk of death in the unit if the patient developed pulmonary oedema when compared to the other factors combined (p = 0.0002, RR = 11.7, 95%CI = 1.7 - 82.).

CONCLUSION

Primiparity, unbooked status and caesarean delivery were leading factors for ICU admission in women with preeclampsia/eclampsia. The women who developed pulmonary oedema in the course of treatment had poor outcome and avoidance of pulmonary oedema may improve ICU outcome in women with preeclampsia/eclampsia.

Baseline assessment of a hospital-specific early warning trigger system for reducing maternal morbidity

OBJECTIVE

To determine whether predefined maternal early warning triggers (MEWTs) can predict pregnancy morbidity.

METHODS

In a retrospective case-control study, obstetric patients admitted to the intensive care unit (ICU) between 2012 and 2013 at seven pilot US hospitals were compared with control patients who had a normal delivery outcome. Six MEWTs were assessed.

RESULTS

The case and control groups each contained 50 patients. Hemorrhage (15/50, 30%), sepsis (12/50, 24%), cardiac dysfunction (8/50, 16%), and pre-eclampsia (6/50, 12%) were the most common reasons for ICU admission. Significant associations were recorded between ICU admission and tachycardia (OR 5.0, 95% CI 2.1-11.7), mean arterial pressure less than 65 mm Hg (OR 4.5, 95% CI 1.9-10.8), temperature of at least 38°C (OR 44.1, 95% CI 13.0-839.1), and altered mental state (OR 44.1, 95% CI 13.1-839.0). Two or more triggers were persistent for 30 minutes or more in 36 (72%) ICU patients versus 2 (4%) controls (OR 61.7, 95% CI 13.2-288.0). Earlier medical intervention might have led to a lesser degree of maternal morbidity for 31 (62%) ICU patients with at least one MEWT.

CONCLUSION

Persistent MEWTs were present in most obstetric ICU cases. Retrospectively, MEWTs in this cohort seemed to separate normal obstetric patients from those for whom ICU admission was indicated; their use might reduce maternal morbidity.

Guidelines for the Management of a Pregnant Trauma Patient

OBJECTIVE

Physical trauma affects 1 in 12 pregnant women and has a major impact on maternal mortality and morbidity and on pregnancy outcome. A multidisciplinary approach is warranted to optimize outcome for both the mother and her fetus. The aim of this document is to provide the obstetric care provider with an evidence-based systematic approach to the pregnant trauma patient.

OUTCOMES

Significant health and economic outcomes considered in comparing alternative practices.

EVIDENCE

Published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library from October 2007 to September 2013 using appropriate controlled vocabulary (e.g., pregnancy, Cesarean section, hypotension, domestic violence, shock) and key words (e.g., trauma, perimortem Cesarean, Kleihauer-Betke, supine hypotension, electrical shock). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English between January 1968 and September 2013. Searches were updated on a regular basis and incorporated in the guideline to February 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

This guideline is expected to facilitate optimal and uniform care for pregnancies complicated by trauma. Summary Statement Specific traumatic injuries At this time, there is insufficient evidence to support the practice of disabling air bags for pregnant women. (III) Recommendations Primary survey 1. Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan. (III-C) 2. A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content. (III-C) 3. Oxygen supplementation should be given to maintain maternal oxygen saturation > 95% to ensure adequate fetal oxygenation. (II-1B) 4. If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual. (III-C) 5. Two large bore (14 to 16 gauge) intravenous lines should be placed in a seriously injured pregnant woman. (III-C) 6. Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation. (II-3B) 7. After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement of the uterus or left lateral tilt. Care should be taken to secure the spinal cord when using left lateral tilt. (II-1B) 8. To avoid rhesus D (Rh) alloimmunization in Rh-negative mothers, O-negative blood should be transfused when needed until cross-matched blood becomes available. (I-A) 9. The abdominal portion of military anti-shock trousers should not be inflated on a pregnant woman because this may reduce placental perfusion. (II-3B) Transfer to health care facility 10. Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life- nor limb-threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks' gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age. (III-B) 11. When the severity of injury is undetermined or when the gestational age is uncertain, the patient should be evaluated in the trauma unit or emergency room to rule out major injuries. (III-C) Evaluation of a pregnant trauma patient in the emergency room 12. In cases of major trauma, the assessment, stabilization, and care of the pregnant women is the first priority; then, if the fetus is viable (≥ 23 weeks), fetal heart rate auscultation and fetal monitoring can be initiated and an obstetrical consultation obtained as soon as feasible. (II-3B) 13. In pregnant women with a viable fetus (≥ 23 weeks) and suspected uterine contractions, placental abruption, or traumatic uterine rupture, urgent obstetrical consultation is recommended. (II-3B) 14. In cases of vaginal bleeding at or after 23 weeks, speculum or digital vaginal examination should be deferred until placenta previa is excluded by a prior or current ultrasound scan. (III-C) Adjunctive tests for maternal assessment 15. Radiographic studies indicated for maternal evaluation including abdominal computed tomography should not be deferred or delayed due to concerns regarding fetal exposure to radiation. (II-2B) 16. Use of gadolinium-based contrast agents can be considered when maternal benefit outweighs potential fetal risks. (III-C) 17. In addition to the routine blood tests, a pregnant trauma patient should have a coagulation panel including fibrinogen. (III-C) 18. Focused abdominal sonography for trauma should be considered for detection of intraperitoneal bleeding in pregnant trauma patients. (II-3B) 19. Abdominal computed tomography may be considered as an alternative to diagnostic peritoneal lavage or open lavage when intra-abdominal bleeding is suspected. (III-C) Fetal assessment 20. All pregnant trauma patients with a viable pregnancy (≥ 23 weeks) should undergo electronic fetal monitoring for at least 4 hours. (II-3B) 21. Pregnant trauma patients (≥ 23 weeks) with adverse factors including uterine tenderness, significant abdominal pain, vaginal bleeding, sustained contractions (> 1/10 min), rupture of the membranes, atypical or abnormal fetal heart rate pattern, high risk mechanism of injury, or serum fibrinogen < 200 mg/dL should be admitted for observation for 24 hours. (III-B) 22. Anti-D immunoglobulin should be given to all rhesus D-negative pregnant trauma patients. (III-B) 23. In Rh-negative pregnant trauma patients, quantification of maternal-fetal hemorrhage by tests such as Kleihauer-Betke should be done to determine the need for additional doses of anti-D immunoglobulin. (III-B) 24. An urgent obstetrical ultrasound scan should be undertaken when the gestational age is undetermined and need for delivery is anticipated. (III-C) 25. All pregnant trauma patients with a viable pregnancy who are admitted for fetal monitoring for greater than 4 hours should have an obstetrical ultrasound prior to discharge from hospital. (III-C) 26. Fetal well-being should be carefully documented in cases involving violence, especially for legal purposes. (III-C) Obstetrical complications of trauma 27. Management of suspected placental abruption should not be delayed pending confirmation by ultrasonography as ultrasound is not a sensitive tool for its diagnosis. (II-3D) Specific traumatic injuries 28. Tetanus vaccination is safe in pregnancy and should be given when indicated. (II-3B) 29. Every woman who sustains trauma should be questioned specifically about domestic or intimate partner violence. (II-3B) 30. During prenatal visits, the caregiver should emphasize the importance of wearing seatbelts properly at all times. (II-2B) Perimortem Caesarean section 31. A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage. (III-B).

Characteristics, Outcomes, and Predictability of Critically Ill Obstetric Patients: A Multicenter Prospective Cohort Study

OBJECTIVE

To evaluate pregnant/postpartum patients requiring ICUs admission in Argentina, describe characteristics of mothers and outcomes for mothers/babies, evaluate risk factors for maternal-fetal-neonatal mortality; and compare outcomes between patients admitted to public and private health sectors.

DESIGN

Multicenter, prospective, national cohort study.

SETTING

Twenty ICUs in Argentina (public, 8 and private, 12).

PATIENTS

Pregnant/postpartum (< 42 d) patients admitted to ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Three hundred sixty-two patients were recruited, 51% from the public health sector and 49% from the private. Acute Physiology and Chronic Health Evaluation II was 8 (4-12); predicted/observed mortality, 7.6%/3.6%; hospital length of stay, 7 days (5-13 d); and fetal-neonatal losses, 17%. Public versus private health sector patients: years of education, 9 ± 3 versus 15 ± 3; transferred from another hospital, 43% versus 12%; Acute Physiology and Chronic Health Evaluation II, 9 (5-13.75) versus 7 (4-9); hospital length of stay, 10 days (6-17 d) versus 6 days (4-9 d); prenatal care, 75% versus 99.4%; fetal-neonatal losses, 25% versus 9% (p = 0.000 for all); and mortality, 5.4% versus 1.7% (p = 0.09). Complications in ICU were multiple-organ dysfunction syndrome (34%), shock (28%), renal dysfunction (25%), and acute respiratory distress syndrome (20%); all predominated in the public sector. Sequential Organ Failure Assessment (during first 24 hr of admission) score of at least 6.5 presented the best discriminative power for maternal mortality. Independent predictors of maternal-fetal-neonatal mortality were Acute Physiology and Chronic Health Evaluation II, education level, prenatal care, and admission to tertiary hospitals.

CONCLUSIONS

Patients spent a median of 7 days in hospital; 3.6% died. Maternal-fetal-neonatal mortality was determined not only by acuteness of illness but to social and healthcare aspects like education, prenatal control, and being cared in specialized hospitals. Sequential Organ Failure Assessment (during first 24 hr of admission), easier to calculate than Acute Physiology and Chronic Health Evaluation II, was a better predictor of maternal outcome. Evident health disparities existed between patients admitted to public versus private hospitals: the former received less prenatal care, were less educated, were more frequently transferred from other hospitals, were sicker at admission, and developed more complications; maternal and fetal-neonatal mortality were higher. These findings point to the need of redesigning healthcare services to account for these inequities.

Predictors of maternal mortality among critically ill obstetric patients

AIM

Evaluation of the predictors of maternal mortality among critically ill obstetric patients managed at the intensive care unit (ICU).

METHODS

A case control study to evaluate the predictors of maternal mortality among critically ill obstetric patients managed at the intensive care unit (ICU) of the University of Ilorin Teaching Hospital, Ilorin, Nigeria from 1st January 2010 to 30th June 2013. Participants were critically ill obstetric patients who were admitted and managed at the ICU during the study period. Subjects were those who died while controls were age and parity matched survivors. Statistical analysis was with SPSS-20 to determine chi square, Cox-regression and odds ratio; p value < 0.05 was significant.

RESULTS

The mean age of subjects and controls were 28.92 ± 5.09 versus 29.44 ± 5.74 (p = 0.736), the level of education was higher among controls (p = 0.048) while more subjects were of low social class (p = 0.321), did not have antenatal care (p = 0.131) and had partners with lower level of education (p = 0.156) compared to controls. The two leading indications for admission among subjects and controls were massive postpartum haemorrhage and severe preeclampsia or eclampsia. The mean duration of admission was higher among controls (3.32 ± 2.46 versus 3.00 ± 2.58; p = 0.656) while the mean cost of ICU care was higher among the subjects (p = 0.472). The statistical significant predictors of maternal deaths were the patient's level of education, Glasgow Coma Scale (GCS) score, oxygen saturation, multiple organ failure at ICU admission and the need for mechanical ventilation or inotrophic drugs after admission.

CONCLUSION

The clinical state at ICU admission of the critically ill obstetric patients is the major outcome determinant. Therefore, early recognition of the need for ICU care, adequate pre-ICU admission supportive care and prompt transfer will improve the outcome.

[Analysis of the causes for increases in the length of stay in the Recovery Unit of La Paz Maternity Hospital in 2008]

OBJECTIVE

To establish the spectrum of diseases in the obstetric patient that involves an increase in the length of stay in the Recovery Unit of a specialist Maternity Hospital. To analyse the severity of these conditions as regards the means required for their resolu-tion, as well as to identify the factors that influence on post-operative morbidity in the obstetric patient.

MATERIAL AND METHODS

All the case histories of all the patients admitted to the Maternity Hospital Recovery Unit during the year 2008 were reviewed. Those who required a lon-ger stay than usual were selected, which included, those with more than 6hours after a caesarean, and all admissions made during pregnancy, or after dilation and curettage or partum.

RESULTS

Out of a total of 10419 births delivered in 2008, 3000 obstetric patients were ad-mitted to the Maternity Hospital Recovery Unit, of which 285 (9.5%) required critical care. The most frequent cause of increased length of stay was obstetric haemorrhage, followed by hypertensive states of pregnancy. No patients died in this Unit in the year 2008.

CONCLUSIONS

The number of patients who had an increased length of stay in the Mater-nity Hospital Recovery Unit is similar to the percentage of patients who are admitted to Intensive Care Units in countries such as Canada or the United Kingdom, but our Unit had a lower death rate in the year evaluated. The main causes are obstetric haemorrhage and hypertensive states of pregnancy, thus patients with risk factors for developing these complications must be observed closely and monitored.

Delivering obstetrical critical care in developing nations

Obstetrical critical care has not been able to achieve the same level of peaks in developing nations like India, as in the western countries. Numerous factors, including clinical and economical, have played a major role in widening the gap of quality care delivery in severely ill obstetric patients, between the two extreme worlds. Moreover, this wide gap can be, to a large extent, attributable to the lower literacy rates, paucity of research in obstetrical critical care, poverty, lack of awareness, and the sociocultural and behavioral factors prevalent in these developing nations. The most common indication for Intensive Care Unit (ICU) admission of such patients throughout the world is hemorrhage, both antepartum and postpartum. Hypertensive disorders, pre-eclampsia, and its related complications are also major contributory factors for such admissions. The pattern of the disease necessitating such admissions influences maternal mortality to a great extent. The present article reviews the most common indications of obstetrical admissions to the ICU, the challenges and obstacles in the treatment of severely ill obstetric patients, their possible outcome in the developing nations, room for improvement, and the need for a change in the system for better delivery of critical care obstetrical services.

Maternal outcomes in critically ill obstetrics patients: A unique challenge

Background:

A pregnant woman is usually young and in good health until she suffers from some acute injury. Her prognosis will hopefully be better if she receives timely intensive care.

Materials and Methods:

The aims of this study were to study the indications of medical intensive care unit (MICU) transfers for critically ill pregnant and postpartum females, biochemical and hematological profile, organ failure, ICU interventions, outcome of mother/fetus, APACHE II score and its correlation with mortality.

Study Design and Setting:

It is a prospective observational study, carried out in the MICU of a tertiary care teaching hospital over a period of 18 months. One hundred and twenty-two pregnant and postpartum females (up to 42 days after delivery) were studied.

Results and Conclusion:

Maternal age >30 years was associated with high mortality (68.2%). Majority of the females were admitted in the third trimester (50 patients) and postpartum period (41 patients), and mortality was highest in the postpartum period (39%). Increasing parity and gravida was associated with significantly high mortality (59.5%). Acute viral hepatitis E (45 patients) was most common indication for MICU transfer, followed by malaria and pregnancy-induced hypertension. The mortality rate was 30.3%. The most common cause of death was acute viral hepatitis E (24 patients), with hepatic failure (53 patients) being the most common organ failure. Majority of the females (88 patients) were ANC registered. Low Glasgow coma score and high APACHE II score on admission were associated with significantly high mortality (85.2%). Prompt treatment with oseltamivir in H1N1 infection was associated with good maternal and fetal outcomes.

The management of the critically ill obstetric patient

Hypertensive disorders, postpartum hemorrhage, and sepsis are the most common indications for intensive care unit admission among obstetric patients. In general, ICU mortality is low, and better than would be predicted using available mortality prediction tools. Provision of care to this special population requires an intimate understanding of physiologic changes that occur during pregnancy. Clinicians must be aware of the way various diagnostic and treatment choices can affect the mother and fetus. Most clinically necessary radiographic tests can be safely performed and fall under the maternal radiation exposure limit of less than 0.05 Gray (Gy). Careful attention must be paid to acid-base status, oxygenation, and ventilation when faced with respiratory failure necessitating intubation. Cesarean delivery can be justified after 4 minutes of cardiac arrest and may improve fetal and maternal outcomes. The treatment of obstetric patients in the ICU introduces complexities and challenges that may be unfamiliar to many critical care physicians; teamwork and communication with obstetricians is crucial.

Obstetric critical care: A prospective analysis of clinical characteristics, predictability, and fetomaternal outcome in a new dedicated obstetric intensive care unit

A 1 year prospective analysis of all critically ill obstetric patients admitted to a newly developed dedicated obstetric intensive care unit (ICU) was done in order to characterize causes of admissions, interventions required, course and foetal maternal outcome. Utilization of mortality probability model II (MPM II) at admission for predicting maternal mortality was also assessed. During this period there were 16,756 deliveries with 79 maternal deaths (maternal mortality rate 4.7/1000 deliveries). There were 24 ICU admissions (ICU utilization ratio 0.14%) with mean age of 25.21±4.075 years and mean gestational age of 36.04±3.862 weeks. Postpartum admissions were significantly higher (83.33% n=20, P<0.05) with more patients presenting with obstetric complications (91.66%, n=22, P<0.01) as compared to medical complications (8.32% n=2). Obstetric haemorrhage (n=15, 62.5%) and haemodynamic instability (n=20, 83.33%) were considered to be significant risk factors for ICU admission (P=0.000). Inotropic support was required in 22 patients (91.66%) while 17 patients (70.83%) required ventilatory support but they did not contribute to risk factors for poor outcome. The mean duration of ventilation (30.17±21.65 h) and ICU stay (39.42±33.70 h) were of significantly longer duration in survivors (P=0.01, P=0.00 respectively) versus non-survivors. The observed mortality (n=10, 41.67%) was significantly higher than MPM II predicted death rate (26.43%, P=0.002). We conclude that obstetric haemorrhage leading to haemodynamic instability remains the leading cause of ICU admission and MPM II scores at admission under predict the maternal mortality.

Management principles of the critically ill obstetric patient

The goals in management of critically ill obstetric patients involve intensive monitoring and physiologic support for patients with life-threatening but potentially reversible conditions. Management principles of the mother should also take the fetus and gestational age into consideration. The most common reasons for intensive care admissions (ICU) in the United States and United Kingdom are hypertensive disorders, sepsis, and hemorrhage. The critically ill obstetric patient poses several challenges to the clinicians involved in her care, because of the anatomic and physiologic changes that take place during pregnancy.

Maternal severity of illness across levels of care: a prospective, cross-sectional study

BACKGROUND

The severity of illness of women experiencing severe maternal morbidity has not been quantified outside of the intensive care setting yet is likely to have a bearing on clinical needs.

AIM

To examine severity of illness in women with severe maternal morbidity.

METHODS

A prospective observational study of critically ill pregnant and postpartum women was undertaken in intensive care units (ICU), high dependency units (HDU) and delivery suites (DS) of seven tertiary-level hospitals in Melbourne, during 2002-2004. Severity of illness was scored using the Acute Physiology and Chronic Health Evaluation version II (APACHE II) and Therapeutic Intervention Scoring System 28 items (TISS 28).

RESULTS

137 women participated in the study: ICU (n=33), HDU (n=46) and DS (n=58). The mean APACHE II score was 8.6 (95% CI 7.7-9.5) and mean TISS 28 score was 22.5 (95% CI 21.2-23.9). Women in ICU were sicker according to both APACHE II (mean 12.6, 95% CI 8.3-16.9) and TISS 28 (mean 31.5, 95% CI 28.2-35.5) compared to women not admitted to ICU (p<.005). There was no difference in the mean APACHE II scores of women in HDU (7.7, 95% CI 5.5-9.9) and DS (7.0, 95% CI 5.2-8.8; p=.20). Women born outside of Australia were more likely to be admitted to ICU (OR 3.27, 95% CI 1.19-8.97). Known risk factors like multiple pregnancy, age≥35 years and nulliparity were not associated with ICU admission.

CONCLUSIONS

There was no difference in the severity of illness in women cared for in HDU and DS. It was not possible to predict which women would require ICU admission. Measurement of severity of illness adds a valuable dimension to the study of severe maternal morbidity.

Obstetric admissions to an integrated general intensive care unit in a quaternary maternity facility

BACKGROUND

Monash Medical Centre (MMC) is a university-affiliated tertiary referral hospital in Melbourne, Victoria, Australia. The hospital has a large obstetric service and is the only quarternary obstetric unit in Victoria. The intensive care unit (ICU) is a busy 21-bed general unit with a broad casemix. While there is no designated state service obstetric ICU in Victoria, MMC ICU has increasingly tried to accept all obstetric patients referred, from both MMC and externally.

AIM

To provide a local perspective on obstetric intensive care in Australia.

METHODS

A retrospective audit of obstetric ICU admissions over 2 years.

RESULTS

Sixty women were admitted, of whom 46 were postpartum. Twenty-nine women were transferred from external sites. Mean maternal age was 30.7 years, mean gestational age 34.5 weeks and mean Acute Physiology and Chronic Health Evaluation (APACHE) version IIIj score 33. Obstetric haemorrhage was the most common admission diagnosis, followed by hypertensive spectrum disorders. Three women were admitted for induction of labour. Median length of stay was 35 h. Twenty-seven women (45%) required mechanical ventilation. No woman died in the ICU, although one died in hospital post-ICU discharge. No data were collected on neonatal outcomes.

CONCLUSIONS

Critically ill obstetric patients can be managed successfully in a general ICU with obstetric input. It may be sensible to cluster these patients into units that are best equipped to deal with them, especially in the ante- and peripartum period.

Evaluation of standard and modified severity of illness scores in the obstetric patient

PURPOSE

To test discrimination and calibration of APACHE-II and SAPS-II risk prediction scores in a cohort of obstetric patients, and to evaluate the effect of modifying these scores for the physiological changes in pregnancy.

MATERIALS AND METHODS

A retrospective review of obstetric patients, 12 weeks gestation to 48 hours postpartum, admitted to the ICU for more than 24 hours. APACHE-II and SAPS-II, and versions modified for the physiological changes of pregnancy, were evaluated by receiver operating characteristic (ROC) curves and standardized mortality ratios (SMR). Multivariable analysis identified other parameters associated with mortality.

RESULTS

Data were obtained from 332 patients from 5 countries, with a mortality rate of 12%. Mean (± SD) APACHE-II score was 16.8 ± 6.1 and SAPS-II score 26.5 ± 15.8. Good discrimination was demonstrated with area under the ROC curves of 0.82 and 0.78 respectively, with no improvement after modification for altered maternal physiology. APACHE-II overestimated mortality, with an SMR of 0.43 (0.52 after including diagnostic weighting) compared with 0.89 for SAPS-II. Bilirubin, albumin and Glasgow Coma Scale were independently associated with mortality.

CONCLUSION

APACHE-II and SAPS-II are good discriminators of illness severity and may be valuable for comparing obstetric cohorts, but APACHE-II significantly over-estimates mortality.

Pregnant and postpartum admissions to the intensive care unit: a systematic review

PURPOSE

To determine the incidence and characteristics of pregnant and postpartum women requiring admission to an intensive care unit (ICU).

METHODS

Medline, PubMed, EMBASE and CINAHL databases (1990-2008) were systematically searched for reports of women admitted to the ICU either pregnant or up to 6 weeks postpartum. Two reviewers independently determined study eligibility and abstracted data.

RESULTS

A total of 40 eligible studies reporting outcomes for 7,887 women were analysed. All studies were retrospective with the majority reporting data from a single centre. The incidence of ICU admission ranged from 0.7 to 13.5 per 1,000 deliveries. Pregnant or postpartum women accounted for 0.4-16.0% of ICU admissions in study centres. Hypertensive disorders of pregnancy were the most prevalent indication for ICU admission [median 0.9 cases per 1,000 deliveries (range 0.2-6.7)]. There was no difference in the profile of ICU admission in developing compared to developed countries, except for the significantly higher maternal mortality rate in developing countries (median 3.3 vs. 14.0%, p = 0.002). Studies reporting patient outcomes subsequent to ICU admission are lacking.

CONCLUSIONS

ICU admission of pregnant and postpartum women occurs infrequently, with obstetric conditions responsible for the majority of ICU admissions. The ICU admission profile of women was similar in developed and developing countries; however, the maternal mortality rate remains higher for ICUs in developing countries, supporting the need for ongoing service delivery improvements. More studies are required to determine the impact of ICU admission for pregnant and postpartum women.

Obstetric admissions to the intensive care unit in a tertiary referral hospital

PURPOSE

The present study was conducted to evaluate the obstetric admissions to the intensive care unit (ICU) in the setting of a tertiary referral hospital in an attempt to identify the risk factors influencing maternal outcome.

MATERIALS AND METHODS

All of the obstetric patients who seeked care for delivery at the emergency department and who were admitted to the ICU between January 2006 to July 2009 were retrospectively identified. The Simplified Acute Physiology Score (SAPS II) was calculated and the maternal mortality rate was estimated for each patient. The mean SAPS II scores and the mean estimated maternal mortality rates for the surviving patients and the nonsurviving patients were compared.

RESULTS

Seventy-three obstetric patients were admitted to the ICU. There were 9 maternal deaths and 24 fetal deaths. For the surviving group of patients, the mean SAPS II score was 34 and estimated maternal mortality rate was 20%, whereas for the nonsurviving group of patients, the SAPS II score was 64 and estimated maternal mortality rate was 73%. The difference between the surviving group of patients and the nonsurviving group of patients was statistically significant regarding both the mean SAPS II scores and the mean estimated maternal mortality rates.

CONCLUSIONS

Pregnancy-induced hypertensive disorders and hemorrhage appear as the major risk factors influencing maternal outcome in obstetric patients. Considering that the use of the SAPS II scores have enabled the reliable estimation of the mortality rates in the present study, the attempts at defining the focus of care for the obstetric patients who bear the major risk factors and who are admitted to the ICU should be carried out under the guidance of the ICU scoring systems such as the SAPS II.

Maternal critical care in obstetrics

OBJECTIVE

To determine the factors leading to maternal critical care in a tertiary obstetric hospital and the associated trends.

METHODS

We conducted a review of the medical records of all women who required transfer for critical care from a free-standing obstetric unit to a general hospital over a 24-year period (1982-2005).

RESULTS

During the 24-year period there were five maternal deaths directly associated with 122,001 deliveries (4.1/100,000) and, in addition, 117 women were transferred to the general hospital for critical care (1.0/1000). The death-to-transfer ratio was 1 in 23. Of the women transferred, 93/117 (79.5%) required intensive care and 24/117 (20.5%) needed specialized medical or surgical services not available in the obstetric unit. Of the women transferred, 16/117 (13.7%) were antepartum, and 101/117 (86.3%) were postpartum. Hemorrhage and hypertensive disorders combined to make up 56.4% of all maternal transfers. Women with a multiple pregnancy were more likely to require transfer than those with a singleton pregnancy (RR 3.34; 95% CI 1.4-7.59, P=0.01).

CONCLUSION

The majority of maternal transfers for critical care occur postpartum, and in more than half of the cases the reason for transfer is hemorrhage or hypertensive disease. Women with a multiple pregnancy had a significantly greater rate of transfer than those with a singleton, and women with a triplet pregnancy had a greater rate than those with twins. There was a non-significant increase in the number of maternal transfers over the study period.

[Morbidity and mortality of patients with preeclampsia or HELLP syndrome transferred in intensive care]

CONTEXT

During pregnancy, the two leading causes of admission in intensive care are preeclampsia and obstetric haemorrhage. However, there are few studies about preeclamptic patients admitted in intensive care. Our purpose was to determine the outcome of pregnancies with preeclampsia and/or HELLP syndrome admitted in intensive care.

METHODS

We performed a retrospective study between March 1996 and April 2005 in a level III maternity. 533 patients were managed with preeclampsia and/or HELLP syndrome during this period. We compared patients admitted in intensive care with patients who did not require admission in intensive care.

RESULTS

Sixty six patients (12,4%) with preeclampsia and/or HELLP were admitted in intensive care. Severe HELLP syndrome, eclampsia, neurological troubles and acute pulmonary oedema were the four leading causes of admission. The mean duration of admission was 3, 2+/-2,9 days. Mean age of the patients (28, 2+/-5,8 vs. 29,0+/-5,8 years, NS) and number of primiparous (71, 2% vs 66,6%, NS) were similar between the two groups. The mean gestational age of delivery was reduced when patients were needed admission in intensive care (29,8+/-3,9 weeks of gestation versus 32,5+/-4,4, p<0,001). 77, 3% of babies survived in the intensive care group compared with 90,4% in the other group (p<0,01).

CONCLUSION

The short-term outcome of patients admitted in intensive care for preeclampsia or HELLP syndrome is generally good. However, neonatal morbidity and mortality remained important when women needed management in intensive care.

Fetal outcomes of critically ill pregnant women admitted to the intensive care unit for nonobstetric causes

INTRODUCTION

The outcome of the fetus in critically ill mothers has been briefly reported as a part of descriptive studies focusing on maternal risk factors for admission to the intensive care unit. We evaluated the risk factors for adverse fetal outcomes in critically ill pregnant women admitted to the intensive care unit for nonobstetrical reasons.

DESIGN

Retrospective cohort study of all critically ill pregnant patients >18 yr; admitted to four (medical, surgical, trauma, and mixed medical-surgical) intensive care units at the Mayo Clinic in Rochester, MN; during the period of January 1995 to December 2005. Only pregnant women admitted to the intensive care unit in the antepartum period for nonobstetrical indications were included. Main predictors for fetal outcomes included: maternal comorbidities, obstetrical history, intensive care unit interventions, and intensive care unit complications. Fetal outcomes were defined as spontaneous abortions, neonatal mortality, fetal deaths, admission to the neonatal intensive care unit, neonatal intensive care unit length of stay, and neonatal intensive care unit complications.

RESULTS

A total of 153 adult women (>18 yr) with a diagnosis of pregnancy were admitted to the intensive care unit, of whom 93 pregnant women met the inclusion criteria. Median maternal age was 26 yr (interquartile range 22-33) and median gestational age was 25 wk (interquartile range 8-33). The median maternal Acute Physiologic and Chronic Health Evaluation III score was 27 (interquartile range 17-38). There were 32 fetal losses; 18 were spontaneous abortions and 14 were fetal deaths. Ten neonates required neonatal intensive care unit admission, five for respiratory distress syndrome; and only one neonate died. The median neonatal intensive care unit length of stay was 34 days (interquartile range 15-87). After multivariable logistic regression analysis, the risk factors associated with fetal loss were: presence of maternal shock, odds ratio 6.85 (95% confidence interval 1.16-58, p = 0.04); maternal transfusion of blood products, odds ratio 7.24 (95% confidence interval 1.4-49, p = 0.02); and gestational age, odds ratio 1.2 for every gestational week below 37 wk (95% confidence interval 1.1-1.3, p < 0.001).

CONCLUSIONS

Nonobstetrical critical illness in pregnant women significantly affects fetal and neonatal outcomes. Maternal shock, maternal requirement of allogenic blood product transfusion and lower gestational age were associated with an increased risk of fetal loss.

Prevalence and risk factors of severe obstetric haemorrhage

OBJECTIVE

To determine the prevalence, causes, risk factors and acute maternal complications of severe obstetric haemorrhage.

DESIGN

Population-based registry study.

POPULATION

All women giving birth (307,415) from 1 January 1999 to 30 April 2004 registered in the Medical Birth Registry of Norway. Information about socio-economic risk factors was obtained from Statistics Norway.

METHODS

Cross-tabulation was used to study prevalence, causes and acute maternal complications of severe obstetric haemorrhage. Associations of severe obstetric haemorrhage with demographic, medical and obstetric risk factors were estimated using multiple logistic regression models.

MAIN OUTCOME MEASURE

Severe obstetric haemorrhage (blood loss of > 1500 ml or blood transfusion).

RESULTS

Severe obstetric haemorrhage was identified in 3501 women (1.1%). Uterine atony, retained placenta and trauma were identified causes in 30, 18 and 13.9% of women, respectively. The demographic factors of a maternal age of > or =30 years and South-East Asian ethnicity were significantly associated with an increased risk of haemorrhage. The risk was lower in women of Middle Eastern ethnicity, more than three and two times higher for emergency caesarean delivery and elective caesarean than for vaginal birth, respectively, and substantially higher for multiple pregnancies, von Willebrand's disease and anaemia (haemoglobin <9 g/dl) during pregnancy. Admissions to an intensive care unit, postpartum sepsis, hysterectomy, acute renal failure and maternal deaths were significantly more common among women with severe haemorrhage.

CONCLUSION

The high prevalence of severe obstetric haemorrhage indicates the need to review labour management procedures. Demographic and medical risk factors can be managed with extra vigilance.

Infection in obstetric critical care

Infections in critically ill obstetric patients are observed worldwide, although the incidence, aetiology and patient outcome vary between geographic locations. This chapter focuses on sepsis, with emphasis on the pathophysiology, outcome and specific management issues.

Outreach in obstetric critical care

The present chapter considers the evolving role of critical care outreach in the general hospital setting and applied to obstetric patients, the mechanics of transferring critically ill obstetric patients to critical care and radiology areas, the scoring systems in use in critical care, and the difficulties in applying these scoring systems to obstetric patients.

Epidemiology of obstetric critical care

In the last 20 years, in developed countries, maternal mortality rates have fallen such that analysis of cases of severe maternal morbidity is necessary to provide sufficient numbers to give a clinically relevant assessment of the standard of maternal care. Different approaches to the audit of severe maternal morbidity exist, and include need for intensive care, organ system dysfunction and clinically defined morbidities. In both developed and developing countries, the dominant causes of severe morbidity are obstetric haemorrhage and hypertensive disorders. In some low-resource regions, obstructed labour and sepsis remain significant causes of severe maternal morbidity. The death to severe morbidity ratio may reflect the standard of maternal care. Audits of severe maternal morbidity should be complementary to maternal mortality reviews.

Clinical characteristics and outcomes of obstetric patients requiring ICU admission

OBJECTIVES

To review a series of critically ill obstetric patients admitted to our ICU to assess the spectrum of disease, required interventions, and fetal/maternal mortality, and to identify conditions associated with maternal death.

DESIGN

Retrospective cohort.

SETTING

Medical-surgical ICU in a university-affiliated hospital.

PATIENTS

Pregnant/postpartum admissions between January 1, 1998, and September 30, 2005.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

We studied 161 patients (age, 28 +/- 9 years; mean gestational age, 29 +/- 9 weeks) [mean +/- SD], constituting 10% of 1,571 hospital admissions. APACHE (acute physiology and chronic health evaluation) II score was 14 +/- 8, with 24% predicted mortality; sequential organ failure assessment score was 5 +/- 3; and therapeutic intervention scoring system at 24 h was 25 +/- 9. Forty-one percent of patients required mechanical ventilation (MV). ARDS, shock, and organ dysfunction were present in 19%, 25%, and 48% of patients, respectively. Most patients (63%) were admitted postpartum, and 74% of admissions were of obstetric cause. Hypertensive disease (40%), major hemorrhage (16%), septic abortion (12%), and nonobstetric sepsis (10%) were the principal diagnoses. Maternal mortality was 11%, with multiple organ dysfunction syndrome (44%) and intracranial hemorrhage (39%) as main causes. There were no differences in death rate in patients admitted for obstetric and nonobstetric causes. Fetal mortality was 32%. Only 30% of patients received antenatal care, which was more frequent in survivors (33% vs 6% nonsurvivors, p = 0.014).

CONCLUSIONS

Although ARDS, organ failures, shock, and use of MV were extremely frequent in this population, maternal mortality remains within an acceptable range. APACHE II overpredicted mortality in these patients. Septic abortion is still an important modifiable cause of mortality. Efforts should concentrate in increasing antenatal care, which was clearly underprovided in these patients.

Obstetric patients in a surgical intensive care unit: prognostic factors and outcome

The objective of this study was to assess the incidence, prognostic factors and the outcome of obstetric patients admitted in a surgical intensive care unit (SICU) during the ante-partum or postpartum period (within 6 weeks of delivery). Between 1995 and 2002, the patients transferred from the department of obstetrics were retrospectively included into the study. Demographics included: obstetric data, medical and surgical histories, diagnosis, simplified acute physiology score (SAPS II), acute physiology and chronic health evaluation system APACHE II score; and the occurrence of organ failure, therapeutic interventions, length of stay in the SICU and outcome were recorded. During the study period, 364 obstetric patients were admitted to the SICU. Obstetric admissions to the SICU represented 0.6% of all deliveries and the SICU utilisation rate was 14.96%. The main indications for admission were eclampsia (70.6%) and postpartum haemorrhage (16.2%). The overall mortality rate was 16.7% (n = 61). In a logistic regression model, risk factors for death included organ system failure (odds ratio (OR) = 3.95 confidence interval (CI) [1.84 - 8.48], bilirubin >12 mg/l (OR = 1.017 CI [1.00 - 1.03]), and prolonged prothrombin time (OR = 0.97 CI [0.95 - 0.99]). Median length of stay was longer in non- survivors (6.5 +/- 7.3 vs 5.5 +/- 4.6 days). Maternal condition on admission and associated complications are the major determinant of maternal outcome.

Obstetric critical care: a blueprint for improved outcomes

INTRODUCTION

Obstetric patients are generally young and healthy. However, the potential for catastrophic complications is real, and despite the therapeutic advances of the last few decades, maternal morbidity and mortality continue to occur. This may be related to the pregnancy itself, aggravation of a preexisting illness, or complications of the (operative) delivery.

PURPOSE

The purpose of this review is two-fold: first, to provide an update on currently available reports pertaining to important critical care issues of the obstetric patient population and, second, to present current comprehensive treatment options for preeclampsia and massive obstetric hemorrhage because both are responsible for the majority of maternal mortality and morbidity worldwide.

RESULTS

The most common reasons for intensive care unit admission are hypertensive disorders and massive obstetric hemorrhage. Timely delivery and prompt initiation of antihypertensive therapy for severe hypertension form the mainstay of care in preeclampsia. Restoration of circulating blood volume and rapid control of bleeding and impaired coagulation are the main factors in the management of massive obstetric hemorrhage. Puerperal morbidity has become the main topic of quality of care issues in maternity care. Although the Acute Physiology and Chronic Health Evaluation II score is commonly used in the intensive care unit, it does not seem to be appropriate for pregnant women because it overestimates their mortality rates. A high-dependency care unit suits the needs for at least half of the obstetric patient population in need of higher acuity care and will save considerable cost.

CONCLUSION

Emphasis on early detection of maternal problems and prompt referral to tertiary centers with intensive care unit facilities to provide optimum care of the circulation, blood pressure, and respiration at an early stage could minimize the prevalence of multiple organ failure and mortality in critically ill obstetric patients.

Caring for pregnant and postnatal women in intensive care: what do we know?

Critically ill pregnant and postnatal women admitted to intensive care units (ICUs) require highly specialised care, components of which many critical care nurses are unfamiliar with. There are no specialist critical care obstetric centres in Australia, with critically ill obstetric patients admitted to general ICUs. There are no published guidelines and little research that assist critical care nurses to care for such women. Furthermore, the admission of pregnant or postnatal women to ICUs is likely to increase with emerging childbearing patterns in Australia. It is therefore timely to review what we know about caring for critically ill pregnant and postnatal women. This paper analyses the literature on intensive care utilisation by obstetric patients and provides an overview regarding which pregnant and postpartum women require intensive care. The key areas of providing mechanical ventilation to pregnant women and assessment of fetal wellbeing are explored in detail. The most frequent conditions and their treatment, preeclampsia and obstetric haemorrhage, are also reviewed. The establishment of lactation is also considered as the critical carenurse is commonly involved in supporting the woman's endeavour to breastfeed.

A curriculum in critical care medicine for maternal-fetal medicine fellows

OBJECTIVE

Critical care education in maternal-fetal medicine has typically been limited or has been driven entirely by clinical cases. A pilot program was created to systematize critical care training within the context of an existing maternal-fetal medicine fellowship.

DESIGN

The program included a lecture series, a Web-based learning module, specific scenarios played out in a human simulator lab, and a clinical intensive care unit rotation. Fellows' knowledge was assessed by pre- and posttest.

RESULTS

Objective knowledge was demonstrated to increase after 1 yr of training. Fellows' impression of the curriculum was positive.

CONCLUSION

More structured critical care medicine training is feasible within a maternal-fetal medicine fellowship. A multimodal curriculum to teach critical care within a maternal-fetal medicine fellowship appears promising and could be implemented elsewhere. Interest in this area should be cultivated.

Revisão sistemática sobre morbidade materna near miss

Esta revisão sistemática sobre near miss materna objetivou analisar dados de incidência e as definições adotadas de near miss. Procedeu-se uma busca eletrônica em bancos de periódicos científicos e também das referências bibliográficas dos estudos identificados. Foram identificados inicialmente 1.247 estudos, analisados na íntegra 35, sendo 17 excluídos e 18 incluídos. A revisão da lista de referências destes artigos identificou mais vinte, totalizando assim 38 estudos incluídos: vinte com definições de near miss relacionadas à complexidade do manejo, seis de disfunção orgânica, dois com definição mista e dez pela presença de sinais ou entidades clínicas específicas. A razão de near miss média foi de 8,2/mil partos, o índice de mortalidade materna foi 6,3% e a razão caso:fatalidade de 16:1. Conclui-se que a incidência de near miss tende a ser maior nos países em desenvolvimento e quando utilizada a definição de disfunção orgânica. O estudo da morbidade materna near miss pode contribuir para a melhora da atenção obstétrica e subsidiar o combate à morte materna.

Neurologic disorders in pregnancy

BACKGROUND

Neurologic dysfunction, coma, and seizures are common in obstetric patients in the intensive care unit.

OBJECTIVE

To review common neurologic disorders resulting in critical illness in pregnancy.

REVIEW

Obstetric disorders causing coma and seizures include eclampsia, acute fatty liver of pregnancy, and amniotic fluid embolism. Preexisting disorders such as epilepsy may worsen in one-third of pregnant patients, and seizures are common during labor. Changes in hemodynamics, blood volume, and hormonal effects on the vessel wall increase risk of bleeding from berry aneurysms and arteriovenous malformations during pregnancy and the postpartum period. Acute intermittent porphyria produces seizures and hypertension, closely mimicking eclampsia. Cerebral venous sinus thrombosis is common in postpartum patients, especially in developing countries. Brain tumors invariably enlarge during pregnancy because of fluid retention and the presence of estrogen and progesterone receptors on tumor cells. Infections such as cerebral malaria and acute viral hepatitis with fulminant hepatic failure are common causes of coma and seizures during pregnancy in tropical regions of Asia, Africa, and Latin America. Patients may be admitted to the intensive care unit with type II respiratory failure due to myasthenic crisis, Guillain-Barre syndrome and spinal cord disease. Relapses of multiple sclerosis are infrequent during pregnancy but increase in the postpartum period.

CONCLUSIONS

In all instances, the effects of the disorders, diagnostic tests, and treatment on the fetus must be carefully weighed. Prompt delivery may be lifesaving for mother and fetus in conditions such as eclampsia and acute fatty liver of pregnancy; expectant treatment may be more appropriate in others.

Critically ill obstetric patients in an American and an Indian public hospital: comparison of case-mix, organ dysfunction, intensive care requirements, and outcomes

OBJECTIVE

To compare case-mix, health care practices, and outcome in obstetric ICU admissions in inner-city teaching hospitals in economically developed and developing countries.

DESIGN

Retrospective study.

SETTING

Ben Taub General Hospital (BTGH), Houston, Texas, and King Edward Memorial Hospital (KEMH), Mumbai, India.

PATIENTS

Women admitted during pregnancy or 6 weeks postpartum between 1992 and 2001.

MEASUREMENTS AND RESULTS

Patients from BTGH (n=174) and KEMH (n=754) had comparable age, number of organs affected, incidence of medical disorders (30%), liver dysfunction, and thrombocytopenia. Fewer KEMH patients received prenatal care (27 vs 86%) and came to hospital within 24 h of onset of symptoms (60 vs 90%). They had higher APACHE II scores (median 16 vs 10), greater incidence of neurological (63 vs 36%), renal (50 vs 37%), and cardiovascular dysfunction (39 vs 29%). Severe malaria, viral hepatitis, cerebral venous thrombosis, and poisoning were common medical disorders. The BTGH group had higher incidence of respiratory dysfunction (59 vs 46%) and disseminated intravascular coagulation (40 vs 23%), placental anomalies, HELLP syndrome, chorioamnionitis, peripartum cardiomyopathy, puerperal sepsis, urinary infection, bacteremia, substance abuse, and asthma. More BTGH patients required mechanical ventilation and blood component therapy, whereas more KEMH patients needed dialysis. Of BTGH patients, 78.2% were delivered by cesarean section (vs 15.4%). Maternal (2.3 vs 25%) and fetal (13 vs 51%) mortality were lower in BTGH patients.

CONCLUSIONS

There were marked differences in medical diseases, organ failure, and intensive care needs. Higher mortality in the Indian ICU may be due to difference in case mix, inadequate prenatal care, delay in reaching hospital, and greater severity of illness.

Cardiopulmonary complications of pregnancy

OBJECTIVES

To provide an up-to-date review of the literature on the assessment and management of pulmonary and cardiac conditions that may affect women during pregnancy and the postpartum period.

DESIGN

A review of the current literature was performed.

RESULTS

Pregnancy may be complicated by a variety of pregnancy-specific and other cardiopulmonary complications. Management requires knowledge of the cardiopulmonary physiologic changes occurring in pregnancy, the pregnancy-specific conditions that may occur, and the effect of a fetus on maternal care.

CONCLUSIONS

Admission of the pregnant or postpartum woman to the intensive care unit is uncommon but may require specialized knowledge for successful management.

Intensive care use by critically ill obstetric patients: a five-year review

This is a retrospective analysis of all obstetric admissions to the surgical intensive care unit over the five-year period beginning July 1, 1994. The admission diagnosis, mode of delivery, anaesthetic employed and patient outcome were assessed. There were 43 obstetric admissions during this period, with 38 deliveries. This represents 0.32% of the deliveries in this hospital during the study period. The median duration of stay was three days (range 1-21). Haemorrhage and pregnancy-induced hypertension accounted for the majority of obstetric complications. Anaesthesia may have contributed to the admission of eight patients. Eight patients had more than one admission diagnosis. There were two deaths and one case of major morbidity (hypoxic encephalopathy) in this series. Prolonged ventilation and/or inotropic support were generally not required. In conclusion, approximately 3 per 1000 maternities require intensive care in this institution. The majority are discharged after a short stay with good outcome.

Incidence of severe pre-eclampsia, postpartum haemorrhage and sepsis as a surrogate marker for severe maternal morbidity in a European population-based study: the MOMS-B survey

OBJECTIVE

To describe the incidence of three conditions of acute severe maternal morbidity in selected regions in nine European countries.

DESIGN

A population-based questionnaire survey.

SETTING

Eleven regions in nine countries of Europe.

POPULATION

All the pregnant women in each region who had delivered during the period covered by the study.

METHODS

Standard definitions of three severe obstetric conditions, pre-eclampsia, postpartum haemorrhage and sepsis were established by a steering committee. A common questionnaire was used in each participating country. The incidence of the three obstetric conditions and characteristics of the study women were compared.

MAIN OUTCOME MEASURES

Incidence of three severe obstetric conditions: pre-eclampsia, postpartum haemorrhage and sepsis.

RESULTS

The study identified 1734 women with at least one of the three conditions, with 847 experiencing severe haemorrhage, 793 experiencing severe pre-eclampsia and 142 experiencing severe sepsis. There were wide variations in incidence of three conditions combined, ranging from 14.7 per thousand deliveries in Brussels, Belgium to 6.0 per thousand deliveries in Upper Austria.

CONCLUSIONS

This study sets a simple and straightforward approach to the definition of three severe obstetric conditions and allows population-based comparisons between developed countries in Europe, even though difficulties may have been present with applying the definition across countries. The reported incidence of these severe obstetric conditions in general and severe haemorrhage varied significantly between countries. Overall, severe haemorrhage in particular was the most common of the three conditions, followed closely by severe pre-eclampsia.

Critical illness and pregnancy: review of a global problem

Obstetric patients are a small but important group of patients in the intensive care unit (ICU). Their problems are unique and need specialized attention. Decision making may be confounded by physiologic changes in pregnancy. In developed countries with good antenatal care, comparatively fewer obstetric patients are admitted to ICUs, but the maternal mortality rate remains high in the developing countries. Medical disorders and organ dysfunction caused by critical illness of pregnancy differ from region to region. With improvement in antenatal care, the number of ICU admissions for obstetric disorders would decline in developing countries; however, this number may increase gradually in developed countries because of increasing maternal age and pregnancies in women with complicated chronic medical disorders.