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Gupta H, Gandotra N, Mahajan R. Profile of Obstetric Patients in Intensive Care Unit: A Retrospective Study from a Tertiary Care Center in North India. Indian J Crit Care Med 2021; 25:388-391. [PMID: 34045804 PMCID: PMC8138638 DOI: 10.5005/jp-journals-10071-23775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Critically ill obstetric patients constitute a small number of intensive care unit (ICU) admissions. Physiological changes in pregnancy along with certain pregnancy-specific diseases may cause a rapid worsening of the health status of the patient necessitating ICU care. The present study aims to study the clinical profile of the obstetric patients requiring ICU care. Materials and methods It was a retrospective analysis of pregnant/postpartum (up to 6 weeks) admissions over a period of 18 months. Results Over these 18 months, 127 women required ICU admission. The most common reasons for ICU admission were obstetric hemorrhage (37.79%) and (pre)eclampsia (28.35%). Ten patients presented with antepartum hemorrhage (placenta previa, placenta accreta, placenta increta). The rest of the patients (n = 38) had atonic postpartum hemorrhage with five having severe anemia. Among the nonobstetric causes (n = 26/127), ICU admission was the most common among those with preexisting heart diseases (n = 10; 7.87%). Forty-nine patients were ventilated mechanically (38.58%), with eclampsia being the most common primary diagnosis (n = 23). We observed 10 maternal deaths (7.87%) with septicemia being the most important cause of death. Conclusions Maternal and child health has become an important measure of human and social development. Early diagnosis and prompt treatment of high-risk obstetric patients in a dedicated obstetric ICU in tertiary hospitals can prevent severe maternal morbidity and improve maternal care. How to cite this article Gupta H, Gandotra N, Mahajan R. Profile of Obstetric Patients in Intensive Care Unit: A Retrospective Study from a Tertiary Care Center in North India. Indian J Crit Care Med 2021;25(4):388–391.
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Affiliation(s)
- Heena Gupta
- Department of Anesthesiology and Critical Care, Government Medical College, Jammu, Jammu and Kashmir, India
| | - Nikita Gandotra
- Department of Obstetrics and Gynaecology, Government Medical College, Jammu, Jammu and Kashmir, India
| | - Ruhi Mahajan
- Department of Biochemistry, Government Medical College, Jammu, Jammu and Kashmir, India
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Kern-Goldberger AR, Moroz L, Friedman A, Purisch S, D'Alton M, Gyamfi-Bannerman C. An assessment of baseline risk factors for peripartum maternal critical care interventions. J Matern Fetal Neonatal Med 2020; 35:3053-3058. [PMID: 32777968 DOI: 10.1080/14767058.2020.1803258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Maternal morbidity presents a growing challenge to the American healthcare system and increasing numbers of patients are requiring higher levels of care in pregnancy. Identifying patients at high risk for critical care interventions, including intensive care unit admission, during delivery hospitalizations may facilitate appropriate multidisciplinary planning and lead to improved maternal safety. Baseline risk factors for critical care in pregnancy have not been well-described previously. OBJECTIVE This study assesses baseline factors associated with critical care interventions that were present at admission for delivery. STUDY DESIGN This is a secondary analysis of a multicenter observational registry of pregnancy after prior uterine surgery and primary cesarean delivery. All women with known gestational age were included. The primary outcome measure was a composite of critical care interventions that included postpartum intensive care unit admission, mechanical ventilation, central intravenous access, and arterial line placement. Risk for this critical care outcome measure was compared by selected baseline and obstetric characteristics known at the time of hospital admission, including maternal age, pre-pregnancy BMI, race, maternal co-morbidities, parity, and plurality. We evaluated these potential predictors and fit a multivariable logistic regression model to ascertain the most significant risk factors for critical care during a delivery hospitalization. RESULTS 73,096 of 73,257 women in the parent trial met inclusion criteria, of whom 505 underwent a critical care intervention (0.7%). In the adjusted model, heart disease [aOR = 10.05, CI = 6.97 - 14.49], renal disease [aOR = 2.78, CI = 1.49 - 5.18], and connective tissue disease [aOR = 3.27, CI = 1.52 - 6.99], as well as hypertensive disorders of pregnancy [aOR = 2.04, CI = 1.31 - 3.17] were associated with the greatest odds of critical care intervention [p < .01] (Table 2). Other predictors associated with increased risk included maternal age, African American race, smoking, diabetes, asthma, anemia, nulliparity, and twin pregnancy. CONCLUSION In this cohort, women with cardiac disease, renal disease, connective tissue disease and preeclampsia spectrum disorders were at increased risk for critical care interventions. Obstetric providers should assess patient risk routinely, ensure appropriate maternal level of care, and create multidisciplinary plans to improve maternal safety and reduce risk.
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Affiliation(s)
- Adina R Kern-Goldberger
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Leslie Moroz
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA.,Division of Maternal-Fetal Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Alexander Friedman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA.,Division of Maternal-Fetal Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Stephanie Purisch
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA.,Division of Maternal-Fetal Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Mary D'Alton
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA.,Division of Maternal-Fetal Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA.,Division of Maternal-Fetal Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Indications and characteristics of obstetric patients admitted to the intensive care unit: a 22-year review in a tertiary care center. Obstet Gynecol Sci 2018; 61:209-219. [PMID: 29564311 PMCID: PMC5854900 DOI: 10.5468/ogs.2018.61.2.209] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 08/21/2017] [Accepted: 08/24/2017] [Indexed: 11/08/2022] Open
Abstract
Objective Reviewing indications and characteristics of obstetric patients admitted to the intensive care unit (ICU) of a tertiary care center, comparing those patients by time period and place of delivery, and to verify clinical utility of acute physiology and chronic health evaluation (APACHE) II score in ICU-admitted women. Methods Retrospective analyses were carried out for parturients admitted to the ICU of our institution from 1994 to 2015. Clinical characteristics were compared between time period (period 1: 1994-2004; period 2: 2005-2015) and place of delivery (our institution and local hospitals). Receiver operating characteristic (ROC) curve analysis was used to evaluate the usefulness of APACHE II score to predict maternal mortality. Results During 22-year period, 176 women required ICU admission, showing the incidence of 2.2 per 1,000 deliveries. The most common reason for ICU admission was postpartum hemorrhage (56.3%), followed by hypertensive disorders (19.3%), sepsis (3.4%), and pulmonary and amniotic fluid embolism (2.3%). Period 2 showed older maternal age (32.7±4.8 vs. 30.8±4.4 years, P=0.006, higher embolization rate (26.4% vs.1.2%, P<0.001), and lower hysterectomy rate (30.8% vs. 49.4%, P=0.012). Cases from local hospitals showed significantly higher proportion of postpartum hemorrhage (84.5% vs. 42.2%, P<0.001). Overall maternal death occurred in 5.1% (9/176) including 6 direct maternal deaths. The APACHE II score showed area under the ROC curve of 0.813 (confidence interval [CI], 0.607-1.000) for prediction of maternal mortality. Conclusion The incidence of obstetric ICU admission was 2.2 per 1,000 deliveries and the most common reason was postpartum hemorrhage followed by hypertensive disorders. APACHE II score could be used to predict mortality in obstetric ICU admission.
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Dhillon NK, Ko A, Smith EJT, Kharabi M, Castongia J, Nurok M, Gewertz BL, Ley EJ. Potentially Avoidable Surgical Intensive Care Unit Admissions and Disposition Delays. JAMA Surg 2017; 152:1015-1022. [PMID: 28724143 DOI: 10.1001/jamasurg.2017.2165] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance High health care costs encourage initiatives that avoid overuse of resources and identify opportunities to promote appropriate care. Objective To investigate the causes of potentially avoidable surgical intensive care unit (SICU) admissions and disposition delays to determine whether targeted interventions could decrease these stays. Design, Setting, and Participants This prospective, observational study focused on potentially avoidable SICU days, as determined by observers with input from the rounding intensivists at a 24-bed open SICU at an urban, academic hospital. The preintervention phase occurred from April 6 through June 21, 2015; after implementation of targeted interventions, the postintervention phase occurred from April 4 through June 28, 2016. Data collected included demographic characteristics, reason for admission, and length of stay. All patients admitted to the SICU during the preintervention and postintervention phases were included in the analysis. Interventions Based on results collected in the preintervention phase, targeted interventions were designed and implemented from July 1, 2015, through March 31, 2016, including (1) reducing SICU care for minor traumatic brain injury, (2) optimizing postoperative airway management, (3) enhancing communication between services regarding transfers to the SICU, (4) identifying and facilitating more timely end-of-life conversations and supportive care consultations, and (5) encouraging early disposition of patients to floor beds. Main Outcomes and Measures Changes in the proportion of potentially avoidable SICU days owing to potentially avoidable admissions and/or disposition delays. Results A total of 459 patients (253 men [55.1%] and 206 women [44.9%]; median age, 62 years [interquartile range, 46-75 years]) were admitted during the preintervention and postintervention phases. Of 261 patients admitted during the preintervention period and 245 during the postintervention period, median SICU and hospital length of stay remained unchanged. A reduction was noted in the percentage of postintervention SICU days owing to potentially avoidable admissions (152 of 1168 days [13%] vs 118 of 1338 days [8.8%]; P = .001) and disposition delays (138 of 1168 days [11.8%] vs 97 of 1338 days [7.2%]; P < .001). During the postintervention period, decreases were noted in the SICU days related to the most common sources of potentially avoidable admissions (SICU stay ≤24 hours, airway concerns, and somnolence) and disposition delays (end-of-life decisions and floor bed unavailable) as well as in the overall rate of potentially avoidable days (269 of 1168 days [23%] vs 205 of 1338 days [15.3%]; P < .001). Conclusions and Relevance Nearly one-fourth of SICU days could be categorized as potentially avoidable. Targeted interventions resulted in a significant reduction of potentially avoidable SICU days.
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Affiliation(s)
- Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ara Ko
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J T Smith
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Mayumi Kharabi
- Human-Centered Design Team, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joseph Castongia
- Human-Centered Design Team, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Nurok
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Bruce L Gewertz
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J Ley
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Farzi F, Mirmansouri A, Atrkar Roshan Z, Naderi Nabi B, Biazar G, Yazdipaz S. Evaluation of Admission Indications, Clinical Characteristics and Outcomes of Obstetric Patients Admitted to the Intensive Care Unit of a Teaching Hospital Center: A Five-Year Retrospective Review. Anesth Pain Med 2017; 7:e13636. [PMID: 29181330 PMCID: PMC5696879 DOI: 10.5812/aapm.13636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 03/01/2017] [Accepted: 04/22/2017] [Indexed: 11/16/2022] Open
Abstract
Background Care of obstetric patients has always been a challenge for critical care physicians, because in addition to their complex pregnancy-related disease, fetal viability is considered. Objectives The aim of this study was to review the admission indications, clinical characteristics and outcomes of obstetric patients, admitted to the intensive care unit of Alzzahra teaching hospital affiliated to Guilan University of Medical Sciences, Rasht, Iran. Methods This retrospective cohort study was conducted on pregnant /post-partum (up to 6 weeks) patients admitted to the ICU over a 5-year period from April 2009 to April, 2014. Results Data from 1019 subjects were analyzed. Overall, 90.1% of the patients were admitted in the postpartum period. The most common indications for admission were pregnancy related hypertensive disorders (27.5%) and obstetric hemorrhage (13.5%). Epilepsy (5.4%) and cardiac disease (5.2%) were the most common non-obstetric indications. Conclusions Pregnancy-related hypertensive disorders and obstetric hemorrhage were the main reasons for admission, and epilepsy and cardiac disease were the most common non-obstetric indications. Efforts must be concentrated on increasing antenatal care.
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Affiliation(s)
- Farnoush Farzi
- Department of Anesthesiology, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Ali Mirmansouri
- Department of Anesthesiology, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
- Corresponding author: Ali Mirmansouri, Anesthesiology Research Center, Velayat Hospital, Guilan University of Medical Sciences, Rasht, Guilan, Iran. Tel: +98-9111315314, E-mail:
| | - Zahra Atrkar Roshan
- Department of Statistically, Guilan University of Medical Sciences, Rasht, Iran
| | - Bahram Naderi Nabi
- Department of Anesthesiology, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Gelareh Biazar
- Department of Anesthesiology, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Shima Yazdipaz
- Department of Anesthesiology, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
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Ryan HM, Sharma S, Magee LA, Ansermino JM, MacDonell K, Payne BA, Walley KR, von Dadelszen P. The Usefulness of the APACHE II Score in Obstetric Critical Care: A Structured Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:909-918. [PMID: 27720089 DOI: 10.1016/j.jogc.2016.06.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 05/30/2016] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Helen M Ryan
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC; Department of Family Practice, University of British Columbia, Vancouver BC; Child and Family Research Institute, University of British Columbia, Vancouver BC
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC; Child and Family Research Institute, University of British Columbia, Vancouver BC
| | - Laura A Magee
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC; Child and Family Research Institute, University of British Columbia, Vancouver BC; Department of Medicine, University of British Columbia, Vancouver BC; Institute of Cardiovascular and Cell Sciences, St. George's, University of London, London, UK; Department of Obstetrics and Gynaecology, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - J Mark Ansermino
- Child and Family Research Institute, University of British Columbia, Vancouver BC; Department of Anesthesia, Pharmacology and Therapeutics, University of British Columbia, Vancouver BC
| | - Karen MacDonell
- Library Services, College of Physicians and Surgeons of British Columbia, Vancouver BC
| | - Beth A Payne
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC; Child and Family Research Institute, University of British Columbia, Vancouver BC
| | - Keith R Walley
- Department of Medicine, University of British Columbia, Vancouver BC; Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver BC
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC; Child and Family Research Institute, University of British Columbia, Vancouver BC; Institute of Cardiovascular and Cell Sciences, St. George's, University of London, London, UK; Department of Obstetrics and Gynaecology, St. George's University Hospitals NHS Foundation Trust, London, UK
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Seppänen P, Sund R, Roos M, Unkila R, Meriläinen M, Helminen M, Ala-Kokko T, Suominen T. Obstetric admissions to ICUs in Finland: A multicentre study. Intensive Crit Care Nurs 2016; 35:38-44. [DOI: 10.1016/j.iccn.2016.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 12/12/2015] [Accepted: 03/16/2016] [Indexed: 10/21/2022]
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Rathod AT, Malini KV. Study of Obstetric Admissions to the Intensive Care Unit of a Tertiary Care Hospital. J Obstet Gynaecol India 2015; 66:12-7. [PMID: 27651571 DOI: 10.1007/s13224-015-0750-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 07/10/2015] [Indexed: 12/01/2022] Open
Abstract
PURPOSE To analyze obstetric admissions to intensive care unit and to identify the risk factors responsible for intensive care admission. METHODS This is a retrospective study of all obstetric cases admitted to the intensive care unit over a period of 3 years. Data were collected from case records. The risk factors responsible for ICU admission were analyzed. RESULTS There were 765 obstetric admissions to ICU accounting for 1.24 % of all deliveries. 56.20 % were in the age group of 20-25 years. 38.43 % were in their first pregnancy. 36.48 % of cases were at 37-40 weeks of gestation. Postpartum admissions were 80.91 %. Major conditions responsible were obstetric hemorrhage in 44.05 %, hypertensive disorders of pregnancy in 28.88 %, severe anemia in 14.37 %, heart disease in 12.15 %, and sepsis in 7.97 % of ICU cases. 40.39 % cases required high dependency care. Maternal mortality was seen in 15.55 % of ICU cases. Commonest cause of mortality was hemorrhagic shock (26.89 %) and multiorgan dysfunction syndrome (26.05 %). CONCLUSION Commonest risk factors for ICU admissions are obstetric hemorrhage and hypertensive disorders of pregnancy. Other major risk factors are severe anemia, heart disease, sepsis, more than one diagnosis on admission, and the need for cesarean delivery.
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Affiliation(s)
- Ashakiran T Rathod
- Department of Obstetrics and Gynecology, Bangalore Medical College and Research Institute, No. 620, A4 Block, Krishna Block, National Games Village, Koramangala, Bangalore, Karnataka 560047 India
| | - K V Malini
- Department of Obstetrics and Gynecology, Bangalore Medical College and Research Institute, No. 620, A4 Block, Krishna Block, National Games Village, Koramangala, Bangalore, Karnataka 560047 India
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Ramachandra Bhat PB, Navada MH, Rao SV, Nagarathna G. Evaluation of obstetric admissions to intensive care unit of a tertiary referral center in coastal India. Indian J Crit Care Med 2013; 17:34-7. [PMID: 23833474 PMCID: PMC3701395 DOI: 10.4103/0972-5229.112156] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background and Aim: To evaluate the occurrence, indications, course, interventions, and outcome of obstetric patients admitted to the intensive care unit (ICU). Design: Retrospective study. Setting: ICU of a Medical College Hospital. Materials and Methods: The data collected were age, parity, obstetric status, primary diagnosis, interventions, and outcome of obstetric patients admitted to the ICU from Jan 2005 to June 2011. Results: Total deliveries were 16,804 in 6.5 years. Obstetric admissions to the ICU were (n = 65) which constitutes 0.39% of deliveries. Majority of the admissions were in the postpartum period (n = 46, 70.8%). The two common indications for admission were obstetric hemorrhage (n = 18, 27.7%) and pregnancy related hypertension with its complications (n = 17, 26.2%). The most common intervention was artificial ventilation (n = 41, 63%). The mortality among obstetric admissions in the ICU was (33.8% (22/65)). The patients appropriate for High Dependency Unit (HDU) care was (32.3% (21/65)). The statistical analysis was done by fractional percentage and Chi-square test. Conclusions: Hemorrhage and pregnancy-related hypertension with its complications are the two common indications for ICU admissions. The need for a HDU should be considered.
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Orsini J, Butala A, Diaz L, Muzylo E, Mainardi C, Kastell P. Clinical Profile of Obstetric Patients Admitted to the Medical-Surgical Intensive Care Unit (MSICU) of an Inner-City Hospital in New York. J Clin Med Res 2012; 4:314-7. [PMID: 23024733 PMCID: PMC3449428 DOI: 10.4021/jocmr1079w] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2012] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Pregnancy is associated with physiological and anatomical changes that usually occur uneventfully in majority of women. However, these changes can cause major maternal morbidity with potential catastrophic consequences. The purpose of this study is to evaluate the clinical characteristics of obstetric patients admitted to the MSICU of an inner-city hospital in New York. METHODS A prospective, observational study was conducted among all the obstetric patients admitted to the MSICU between June 1, 2009 and June 30, 2012. RESULTS A total of 19 obstetric patients were admitted to the MSICU between June 1, 2009 and June 30, 2012. The most common comorbidity on admission was hypertensive disorder. Hemodynamic unstability and shock was the most common admission diagnosis. The mean length of stay was 3.5 days. One patient died. CONCLUSIONS Obstetric hemorrhage and pregnancy-induced hypertensive disorders remains as the most common entities requiring intensive care unit (ICU) admission among obstetric patients. A multidisciplinary team involvement is essential in the management of these patients.
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Affiliation(s)
- Jose Orsini
- Department of Medicine, New York University School of Medicine at Woodhull Medical and Mental Health Center, 760 Broadway, Brooklyn, New York, USA
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Abstract
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.
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Affiliation(s)
- Sukhwinder Kaur Bajwa
- Department of Obstetrics and Gynaecology, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
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Rios FG, Risso-Vázquez A, Alvarez J, Vinzio M, Falbo P, Rondinelli N, Bienzobas DH. Clinical characteristics and outcomes of obstetric patients admitted to the intensive care unit. Int J Gynaecol Obstet 2012; 119:136-40. [DOI: 10.1016/j.ijgo.2012.05.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 05/15/2012] [Accepted: 07/20/2012] [Indexed: 10/28/2022]
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13
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Acute lung inflammatory response and injury after hemorrhagic shock are more severe in postpartum rabbits*. Crit Care Med 2012; 40:1570-7. [DOI: 10.1097/ccm.0b013e3182451c17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ghazal-Aswad S, Badrinath P, Sidky I, Safi TH, Gargash H, Abdul-Razak Y, Mirghani H. Severe Acute Maternal Morbidity in a High-Income Developing Multiethnic Country. Matern Child Health J 2012; 17:399-404. [DOI: 10.1007/s10995-012-0984-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bentata Y, Housni B, Mimouni A, Abouqal R. Admissions of women in the third trimester of pregnancy to an intensive care unit in Morocco over a 4-year period. Int J Gynaecol Obstet 2011; 116:260-1. [PMID: 22196995 DOI: 10.1016/j.ijgo.2011.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 10/31/2011] [Accepted: 11/22/2011] [Indexed: 10/14/2022]
Affiliation(s)
- Yassamine Bentata
- Department of Nephrology, Medical School, University Mohamed First, Oujda-Morocco.
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Pollock WE, Harley NS, Nelson SM. Maternal severity of illness across levels of care: a prospective, cross-sectional study. Aust Crit Care 2011; 24:218-28. [PMID: 21543236 DOI: 10.1016/j.aucc.2011.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Revised: 03/02/2011] [Accepted: 03/29/2011] [Indexed: 10/18/2022] Open
Abstract
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.
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Affiliation(s)
- Wendy E Pollock
- La Trobe University/Mercy Hospital for Women, Midwifery Professorial Unit, Level 4, 163 Studley Rd, Heidelberg, VIC 3084, Australia.
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Kostopanagiotou G, Kalimeris K, Pandazi A, Salamalekis G, Chrelias C, Matsota P. The role of the post-anaesthesia care unit in the management of high-risk obstetric patients. Arch Med Sci 2011; 7:123-6. [PMID: 22291744 PMCID: PMC3258694 DOI: 10.5114/aoms.2011.20616] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Revised: 04/25/2010] [Accepted: 06/18/2010] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION High-risk obstetric patients in the immediate postpartum period are frequently admitted to the intensive care unit, but the necessity of this practice has recently been doubted. Herein we describe the efficiency of utilizing the post-anaesthesia care unit (PACU) as an intermediate intensive care facility for those patients. MATERIAL AND METHODS We retrospectively described the reasons for admission, duration of stay, the anaesthetic used, main interventions and outcome for all obstetric admissions in the PACU during a period of 4 years in a university hospital. RESULTS During the 4-year period 47 women were admitted to the PACU after delivery. The frequency of admission to the PACU was 15.3 per 1000 deliveries, while obstetric cases represented 4.4 per 1000 admissions to the PACU. The majority represented caesarean sections (81%). The main reasons for admission to the PACU were haemorrhage (49%), cardiovascular problems (19%) and preeclampsia/eclampsia (17%). Mean length of stay in the PACU was 14.5 ±11.6 h, being significantly less in women having received epidural anaesthesia (8.2 ±5.6 h) compared to those who delivered with general anaesthesia (19.0 ±13.6 h, p < 0.05). General anaesthesia was used in 85% of cases in which emergency delivery was indicated, but only in 27% of cases without emergency indications for delivery (p < 0.01). No death or admission to the intensive care unit occurred during the study period. CONCLUSIONS The PACU can offer an intermediate intensive care facility for high-risk obstetric patients, thus reducing unnecessary admissions to the intensive care unit.
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Affiliation(s)
- Georgia Kostopanagiotou
- 2 Department of Anaesthesiology, University of Athens School of Medicine, Attikon Hospital, Athens, Greece
| | - Konstantinos Kalimeris
- 2 Department of Anaesthesiology, University of Athens School of Medicine, Attikon Hospital, Athens, Greece
| | - Aggeliki Pandazi
- 2 Department of Anaesthesiology, University of Athens School of Medicine, Attikon Hospital, Athens, Greece
| | - George Salamalekis
- 3 Department of Obstetrics and Gynaecology, University of Athens School of Medicine, Attikon Hospital, Athens, Greece
| | - Charalampos Chrelias
- 3 Department of Obstetrics and Gynaecology, University of Athens School of Medicine, Attikon Hospital, Athens, Greece
| | - Paraskevi Matsota
- 2 Department of Anaesthesiology, University of Athens School of Medicine, Attikon Hospital, Athens, Greece
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Khawaga S, Ei Sayed N, Shaikh N, Mustafa G, Kettern M, Hafiz A. Critical Care of Gynecological and Obstetric Patients: A decade of surgical intensive care experience. Qatar Med J 2010. [DOI: 10.5339/qmj.2010.2.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Despite the emergence of therapeutic advances, the morbidity and mortality still occur in the obstetric patients, although intensive care utilization by obstetric and gynecological patient, are still rare compared to the general population. Majority of obstetric patients needed the intensive care therapy compared to gynecological patients. The aim of our study was to know the indications for the intensive care admission by obstetric and gynecological patients, length of stay and outcome of these patients.
Methods: We retrospectively reviewed the medical records of all obstetric and gynecological patients admitted to our Surgical and Trauma Intensive Care Units (SICU and TICU) from February 1995 to March 2005. Indication for admission, nationality, age, and length of stay in ICU, severity of disease and outcome of these patients were recorded. Data analyzed with SPSS program.
Results: A total of 182 patients were admitted to the SICU of the Hamad Medical Corporation in Doha, Qatar, from the Women's Hospital. 159 (87%) patients were obstetric patients and 23 (13%) patients gynecological patients, 126 (69.6%) patients were admitted post Lower Segment Caesarean Section (LSCS). The most common indication for admission was 73 (39.3%) patients obstetric hemorrhage and Disseminated Intravascular Coagulation (DIC), and then 44 (25.3%) patients of hypertensive disorder of pregnancy. The major anesthesia related indication was scoline apnea, 21 (11.6%). Total three obstetric patients died, two due to severe sepsis and multi-organ failure and one due to cerebral sinus thrombosis, giving mortality rate of 1.66%.
Conclusion: Intensive care therapy required by gynecological and obstetric patient is less than the general population. The commonest indication for admission was obstetric hemorrhage, DIC, and hypertensive disorders of pregnancy. The mortality was due to septic shock with multi-organ failure, and cerebral venous sinus thrombosis.
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Affiliation(s)
- S. Khawaga
- Department of Obstetrics and Gynecology; Anesthesia and Pain Management Department Hamad Medical Corporation, Doha, Qatar
| | - N. Ei Sayed
- Department of Obstetrics and Gynecology; Anesthesia and Pain Management Department Hamad Medical Corporation, Doha, Qatar
| | - N. Shaikh
- Department of Obstetrics and Gynecology; Anesthesia and Pain Management Department Hamad Medical Corporation, Doha, Qatar
| | - G. Mustafa
- Department of Obstetrics and Gynecology; Anesthesia and Pain Management Department Hamad Medical Corporation, Doha, Qatar
| | - M.A. Kettern
- Department of Obstetrics and Gynecology; Anesthesia and Pain Management Department Hamad Medical Corporation, Doha, Qatar
| | - A. Hafiz
- Department of Obstetrics and Gynecology; Anesthesia and Pain Management Department Hamad Medical Corporation, Doha, Qatar
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Bajwa SK, Bajwa SJS, Kaur J, Singh K, Kaur J. Is intensive care the only answer for high risk pregnancies in developing nations? J Emerg Trauma Shock 2010; 3:331-6. [PMID: 21063554 PMCID: PMC2966564 DOI: 10.4103/0974-2700.70752] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Accepted: 07/08/2010] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Management of high risk obstetric patients. AIM The present study was conducted to evaluate the primary causes of the admission of obstetric patients to Intensive Care Unit (ICU), the presence of co-morbid diseases, outcome of such patients, their survival rate as well as the factors which contribute to the maternal mortality. SETTINGS AND DESIGN A retrospective study was conducted in the Department of Obstetrics and Gynaecology and Anaesthesiology/ICU of our Institute. MATERIALS AND METHODS Sixty-one obstetric patients, who were admitted to ICU between 20 December 2006 and 31 January 2010, were evaluated for various factors responsible for their admission as well as their outcome. STATISTICAL ANALYSIS At the end of study, the data were arranged systematically and subjected to statistical analysis using nonparametric tests and P value <0.05 was considered significant. RESULTS Majority of the 61 patients admitted in ICU were referred from the peripheral health centers, smaller nursing homes/hospitals and some even without proper primary care and mainly comprising uneducated and rural population. Hemorrhage, pregnancy induced hypertension, cardiac diseases, respiratory insufficiency and sepsis were the main causes for admission. A total of 18 patients among 61 died during their ICU stay in the hospital. CONCLUSIONS In the developing countries, high risk pregnancy should be managed at peripheral centers with proper facilities, antenatal visits and timely referral. The intensive care help should be reserved for very high risk pregnancies with co-morbid diseases.
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Affiliation(s)
| | | | - Jasbir Kaur
- Department of Anaesthesiology and Intensive Care Ram Nagar, Banur, India
| | - Kamaljit Singh
- Department of Biochemistry Gian Sagar Medical College and Hospital (GSMCH), Ram Nagar, Banur, India
| | - Jasleen Kaur
- Department of Obstetrics and Gynaecology, Patiala, Punjab, India
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Lataifeh I, Amarin Z, Zayed F, Al-Mehaisen L, Alchalabi H, Khader Y. Indications and outcome for obstetric patients' admission to intensive care unit: a 7-year review. J OBSTET GYNAECOL 2010; 30:378-82. [PMID: 20455722 DOI: 10.3109/01443611003646298] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The objective of this retrospective study was to investigate the indications, interventions and clinical outcome of pregnant and newly delivered women admitted to the multidisciplinary intensive care unit at the King Abdullah University Hospital in Jordan over a 7-year period from January 2002 to December 2008. The collected data included demographic characteristics of the patients, mode of delivery, pre-existing medical conditions, reason for admission, specific intervention, length of stay and maternal outcome. A total of 43 women required admission to the intensive care unit (ICU), which represented 0.37% of all deliveries. The majority (95.3%) of patients were admitted to the ICU postpartum. The most common reasons for admissions were (pre)eclampsia (48.8%) and obstetric haemorrhage (37.2). The remainder included adult respiratory distress syndrome (6.9%), pulmonary embolism (2.3%) and neurological disorders (4.6%). Mechanical ventilation was required to support 18.6% of patients and transfusion of red blood cells was needed for 48.8% of patients. There were three maternal deaths (6.9%). A multidisciplinary team approach is essential to improve the management of hypertensive disorders and postpartum haemorrhage to achieve significant improvements in maternal outcome. A large, prospective study to know which women are at high risk of admission to the intensive care units and to prevent serious maternal morbidity and mortality is warranted.
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Affiliation(s)
- I Lataifeh
- Department of Obstetrics and Gynaecology, Jordan University of Science and Technology, Irbid, Jordan.
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Pregnant and postpartum admissions to the intensive care unit: a systematic review. Intensive Care Med 2010; 36:1465-74. [PMID: 20631987 DOI: 10.1007/s00134-010-1951-0] [Citation(s) in RCA: 133] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2009] [Accepted: 05/27/2010] [Indexed: 12/11/2022]
Abstract
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.
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Hanson J, Lee SJ, Mohanty S, Faiz MA, Anstey NM, Charunwatthana P, Yunus EB, Mishra SK, Tjitra E, Price RN, Rahman R, Nosten F, Htut Y, Hoque G, Hong Chau TT, Hoan Phu N, Hien TT, White NJ, Day NPJ, Dondorp AM. A simple score to predict the outcome of severe malaria in adults. Clin Infect Dis 2010; 50:679-85. [PMID: 20105074 PMCID: PMC4313369 DOI: 10.1086/649928] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND World Health Organization treatment guidelines recommend that adults with severe malaria be admitted to an intensive care unit (ICU). However, ICU facilities are limited in the resource-poor settings where most malaria occurs. Identification of patients at greater risk of complications may facilitate their triage and resource allocation. METHODS With use of data from a trial conducted in Southeast Asia (n=868), a logistic regression model was built to identify independent predictors of mortality among adults with severe malaria. A scoring system based on this model was tested in the original dataset and then validated in 2 series from Bangladesh (n=188) and Vietnam (n=292). RESULTS Acidosis (base deficit) and cerebral malaria (measured as Glasgow Coma Score) were the main independent predictors of outcome. The 5-point Coma Acidosis Malaria (CAM) score was simply derived from these 2 variables. Mortality increased steadily with increasing score. A CAM score <2 predicted survival with a positive predictive value (PPV) of 95.8% (95% confidence interval [CI], 93%- 97.7%). Of the 14 of 331 patients who died with a CAM score <2, 11 (79%) had renal failure and death occurred late after hospital admission (median, 108 h; range, 40-360 h). Substitution of plasma bicarbonate as the measure of acidosis only slightly reduced the prognostic value of the model. Use of respiratory rate was inferior, but a score <2 still predicted survival with a PPV of 92.2% (95% CI, 89.1%-94.7%). CONCLUSIONS Patients with a CAM score <2 at hospital admission may be safely treated in a general ward, provided that renal function can be monitored.
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A national survey of obstetric early warning systems in the United Kingdom. Int J Obstet Anesth 2009; 18:253-7. [PMID: 19457651 DOI: 10.1016/j.ijoa.2009.01.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2008] [Revised: 10/31/2008] [Accepted: 01/11/2009] [Indexed: 11/21/2022]
Abstract
BACKGROUND Despite recommendations in the two most recent Confidential Enquiries into Maternal and Child Health (CEMACH) reports, and improvements in patient care using early warning scoring systems (EWS) in the general adult population, no validated system currently exists for the obstetric population. METHODS We performed an Obstetric Anaesthetists' Association (OAA) approved postal survey of all UK consultant-led obstetric anaesthetic units in November 2007 to assess opinions on the value and of such a system and how it could be implemented, and invited comments and samples of systems already in use. RESULTS The response rate was 71%. Of those who replied a median usefulness score of 80% for a standardised national obstetric EWS was demonstrated. Eighty-nine percent of units thought it would be possible to implement a system, and although 96% of UK hospitals already use a non-obstetric EWS, only 23% of respondents thought this to be relevant to obstetric physiology and disease. Nine units returned copies of their obstetric EWS. Using extracts from some of the submitted versions we have designed and implemented a system locally and submitted it to the OAA for consideration. CONCLUSIONS The survey results support CEMACH recommendations for a nationally agreed obstetric EWS.
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[Morbidity and mortality of patients with preeclampsia or HELLP syndrome transferred in intensive care]. Presse Med 2009; 38:872-80. [PMID: 19186027 DOI: 10.1016/j.lpm.2008.12.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Revised: 11/26/2008] [Accepted: 12/15/2008] [Indexed: 11/24/2022] Open
Abstract
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.
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Saravanakumar K, Davies L, Lewis M, Cooper GM. High dependency care in an obstetric setting in the UK. Anaesthesia 2008; 63:1081-6. [DOI: 10.1111/j.1365-2044.2008.05581.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
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.
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Grisaru-Granovsky S, Ioscovich A, Hersch M, Schimmel M, Elstein D, Samueloff A. Temporizing treatment for the respiratory-compromised gravida: an observational study of maternal and neonatal outcome. Int J Obstet Anesth 2007; 16:261-4. [PMID: 17399980 DOI: 10.1016/j.ijoa.2006.10.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2006] [Accepted: 10/06/2006] [Indexed: 11/23/2022]
Abstract
Acute lung disease may originate in pregnancy because of the pregnancy itself or because of an intercurrent etiology. The purpose of this study was to describe the effect of prolonged antepartum mechanical ventilatory support on the mother and the neonate when the strategy was to prolong the pregnancy rather than deliver preterm. Among 72 312 parturients over eight years, three gravidae required mechanical ventilation 12-48 h after admission for different conditions, 45-91 days before delivery. Gestational age at intubation was 21-28 weeks. Appropriate analgesia, broad-spectrum antibiotics, vasopressors and betamethsone for fetal lung maturity were used in all cases. None received tocolysis. Despite uterine distension, respiratory support provided adequate oxygenation and FiO2 could be maintained below critical levels, obviating the need for early delivery. All women survived, were weaned from ventilatory support, discharged, and delivered healthy neonates at term. Mode of delivery was dictated by obstetrical indicators only. All five infants (two sets of twins) are healthy at 12-36 months with appropriate developmental milestones. We conclude that when the maternal condition is amenable to therapy, and given the risks of labor induction and of prematurity, there is only limited benefit of delivery while on mechanical ventilation.
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Affiliation(s)
- S Grisaru-Granovsky
- Department of Obstetrics and Gynecology, the Intensive Care Unit and Gaucher Clinic, Shaare Zedek Medical Center, Jerusalem, Israel
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Abstract
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.
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Affiliation(s)
- Gerda G Zeeman
- Department of Obstetrics and Gynecology, University Medical Center, Groningen, The Netherlands
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Abstract
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.
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Stevens TA, Carroll MA, Promecene PA, Seibel M, Monga M. Utility of Acute Physiology, Age, and Chronic Health Evaluation (APACHE III) score in maternal admissions to the intensive care unit. Am J Obstet Gynecol 2006; 194:e13-5. [PMID: 16647889 DOI: 10.1016/j.ajog.2006.01.073] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2005] [Revised: 01/06/2006] [Accepted: 01/20/2006] [Indexed: 11/20/2022]
Abstract
OBJECTIVE A mean Acute Physiology, Age, and Chronic Health Evaluation (APACHE III) score of > 50 is associated with increased intensive care unit mortality rate in nonpregnant cardiac and trauma patients. The objective was to determine the usefulness of the APACHE III score in maternal admissions to an intensive care unit in a tertiary care center in an urban multicultural city. STUDY DESIGN This was a retrospective review of all maternal admissions (> 20 weeks of gestation or after delivery) to an intensive care unit between January 2002 and May 2004. Demographics, obstetric and medical history, and 20 physiologic variables that comprise the APACHE III were recorded. The minimum APACHE III score (lowest risk of death) is 0; maximum is 299. The association between APACHE III score and maternal death was assessed with Mann Whitney U test. Significance was assumed at a probability value of < .05. RESULTS Fifty-eight subjects met the study criteria. Thirty percent of these women were admitted antepartum (27 +/- 1.0 weeks of gestation); 31% of the women were admitted on the day of delivery; and 29% of the women were admitted after delivery. Mean maternal age was 27 +/- 6.7 years. Acute conditions that resulted in transfer to the intensive care unit included preeclampsia (24%), cardiorespiratory disease (21%), hemorrhage (16%), infection (12%), trauma (7%), and thromboembolism (3%). Fifty-five percent of the women had no previous underlying obstetric complications, and 98% of the women had no underlying chronic health condition. Fifty-eight percent of the women received care in a medical intensive care unit; 28% of the women received care in a surgical intensive care unit; 10% of the women received care in a cardiac intensive care unit, and 3% of the women received care in a neurologic intensive care unit. The mean intensive care unit stay was 3.7 +/- 4.6 days, and the mean hospital stay was 9.0 +/- 7 days. Three patients died; the rest of the patients went home in good condition. The median APACHE III score was 34 (range, 14-102) and was not correlated with maternal death. CONCLUSION The APACHE III is not associated with risk of intensive care unit-related maternal death.
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Affiliation(s)
- Tobey A Stevens
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Medical School Houston, TX, USA
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Simpson KR. Critical illness during pregnancy: considerations for evaluation and treatment of the fetus as the second patient. Crit Care Nurs Q 2006; 29:20-31. [PMID: 16456360 DOI: 10.1097/00002727-200601000-00003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
When a critically ill woman is pregnant, clinical interventions for the mother can have a profound effect on fetal status. It is essential that the fetus be considered as the second patient when developing the plan of care. The most practical solution for providing comprehensive care to pregnant women in the intensive care unit (ICU) is a collaborative approach involving members of the ICU and the perinatal team, each contributing their unique knowledge and skills to the care of the mother and her unborn baby. The purpose of this article is to describe a collaborative approach to caring for a pregnant woman in the ICU along with a brief overview of fetal assessment for ICU care providers so they can become familiar with terms and methods used in assessing fetal status and common interventions that promote fetal well-being.
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