Pregnant and postpartum admissions to the intensive care unit: a systematic review. Intensive Care Med. 2010;36:1465-1474. [PMID: 20631987 DOI: 10.1007/s00134-010-1951-0]

Critical care admissions and outcomes in pregnant and postpartum women: a systematic review

PURPOSE

To synthesise evidence for the incidence of intensive care unit (ICU) admission, characteristics and mortality of pregnant and postpartum women with a focus on differences between high-income countries (HICs) and low-middle-income countries (LMICs) and report changes in reported findings since the last review by Pollock et al. (2010).

METHODS

We searched Ovid Medline, EMBASE, and CINAHL (2010-2023), following best practice guidelines for abstract screening for large-evidence systematic reviews. Patient and study characteristics of extracted studies were analysed descriptively. Multivariable meta-regression analysis, employing mixed-effects models, was conducted for assessing ICU admission and mortality. Studies reviewed by Pollock et al. were included to perform an overall analysis, including each study period and geographic region in a model.

RESULTS

Seventy-one eligible studies reported data on 111,601 women admitted to ICU, with 41,291,168 deliveries reported in 65 studies. Fifty-six studies were retrospective. Case definitions, admission criteria, and causes of mortality reported were heterogeneous. The pooled ICU admission rate was 1.6% (95% confidence interval [CI] 1.28-1.99; I2 = 99.8%), 0.4% (95% CI 0.32-0.48, I2 = 99.9%) in HICs versus 2.8% (95% CI 0.65-6.4, I2 = 99.9%) in LMICs (p < 0.0001). The pooled ICU mortality rate among 140,780 admissions reported in 63 studies was 6.5% (95% CI 5.2-7.9; I2 = 98.7%), with mortality in HICs 1.4% (95% CI 0.8-2.1, I2 = 98.04%) lower than LMICs 12.4% (95% CI 8.1-17.5, I2 = 98.9%) (p < 0.0001). Multivariable meta-regression analysis found a significant association between the ICU admission rates (p = 0.0001) and mortality (p = 0.0003) with geographic region (HIC vs LMIC). Compared to the earlier study of Pollock et al. in 2010, there was an increase in reported studies (71 vs 40 in Pollock et al. study) and reported admissions (111,601 vs 7887 Pollock et al. study), particularly from LMICs'.

CONCLUSIONS

Mortality for critically ill peripartum women is substantial and the gap in reported ICU admissions and mortality for critically ill peripartum women between HIC and LMICs remains unacceptably high. The reports are often small and heterogeneous using many case definitions. Reporting standards focusing on critical care processes and outcomes and large multinational prospective studies are necessary to better understand and mitigate maternal and child health challenges as sustainable development goals in LMICs and HICs.

The Association of Pregnancy With Outcomes Among Critically Ill Reproductive-Aged Women: A Propensity Score-Matched Retrospective Cohort Analysis

BACKGROUND

The maternal mortality rate in the United States is unacceptably high. However, the relative contribution of pregnancy to these outcomes is unknown. Studies comparing outcomes among pregnant vs nonpregnant critically ill patients show mixed results and are limited by small sample sizes.

RESEARCH QUESTION

What is the association of pregnancy with critical illness outcomes?

STUDY DESIGN AND METHODS

We performed a retrospective cohort study of women 18 to 55 years of age who received invasive mechanical ventilation (MV) on hospital day 0 or 1 or who demonstrated sepsis on admission (infection with organ failure) discharged from Premier Healthcare Database hospitals from 2008 through 2021. The exposure was pregnancy. The primary outcome was in-hospital mortality. We created propensity scores for pregnancy (using patient and hospital characteristics) and performed 1:1 propensity score matching without replacement within age strata (to ensure exact age matching). We performed multilevel multivariable mixed-effects logistic regression for propensity-matched pairs with pair as a random effect.

RESULTS

Three thousand ninety-three pairs were included in the matched MV cohort, and 13,002 pairs were included in the sepsis cohort. The characteristics of both cohorts were well balanced (all standard mean differences, < 0.1). Among matched pairs, unadjusted mortality was 8.0% vs 13.8% for MV and 1.4% vs 2.3% for sepsis among pregnant and nonpregnant patients, respectively. In adjusted regression, pregnancy was associated with lower odds of in-hospital mortality (MV: OR, 0.50; 95% CI, 0.41-0.60; P < .001; sepsis: OR, 0.52; 95% CI, 0.40-0.67; P < .001).

INTERPRETATION

In this large US cohort, critically ill pregnant women receiving MV or with sepsis showed better survival than propensity score-matched nonpregnant women. These findings must be interpreted in the context of likely residual confounding.

Use of Extracorporeal Membrane Oxygenation for Patients with Coronavirus Disease 2019 Infection

The coronavirus disease 2019 (COVID-19) pandemic was a cataclysmic event that infected over 772 million and killed over 6.9 million people worldwide. The pandemic pushed hospitals and society to their limits and resulted in incredibly severe respiratory disease in millions of people. This severe respiratory disease often necessitated maximum medical therapy, including the use of extracorporeal membrane oxygenation. While our understanding of COVID-19 and its treatment continue to evolve, we review the current evidence to guide the care of patients with severe COVID-19 infection.

Design, construction, and validation of obstetric risk classification systems to predict intensive care unit admission

INTRODUCTION

To develop and validate a support tool for healthcare providers, enabling them to make precise and critical decisions regarding intensive care unit (ICU) admissions for high-risk pregnant women, thus enhancing maternal outcomes.

METHODS

This retrospective study involves secondary data analysis of information gathered from 9550 pregnant women, who had severe maternal morbidity (any unexpected complication during labor and delivery that leads to substantial short-term or long-term health issues for the mother), collected between 2009 and 2010 from the Brazilian Network for Surveillance of Severe Maternal Morbidity, encompassing 27 obstetric reference centers in Brazil. Machine-learning models, including decision trees, Random Forest, Gradient Boosting Machine (GBM), and Extreme Gradient Boosting (XGBoost), were employed to create a risk prediction tool for ICU admission. Subsequently, sensitivity analysis was conducted to compare the accuracy, predictive power, sensitivity, and specificity of these models, with differences analyzed using the Wilcoxon test.

RESULTS

The XGBoost algorithm demonstrated superior efficiency, achieving an accuracy rate of 85%, sensitivity of 42%, specificity of 97%, and an area under the receiver operating characteristic curve of 86.7%. Notably, the estimated prevalence of ICU utilization by the model (11.6%) differed from the prevalence of ICU use from the study (21.52%).

CONCLUSION

The developed risk engine yielded positive results, emphasizing the need to optimize intensive care bed utilization and objectively identify high-risk pregnant women requiring these services. This approach promises to enhance the effective and efficient management of pregnant women, particularly in resource-constrained regions worldwide. By streamlining ICU admissions for high-risk cases, healthcare providers can better allocate critical resources, ultimately contributing to improved maternal health outcomes.

Critical pregnancy at altitude: A look at Latin America

Critical pregnancy at high altitudes increases morbidity and mortality from 2500 m above sea level. In addition to altitude, there are other influential factors such as social inequalities, cultural, prehospital barriers, and lack the appropriate development of healthcare infrastructure. The most frequent causes of critical pregnancy leading to admission to Intensive Care Units are pregnancy hypertensive disorders (native residents seem to be more protected), hemorrhages and infection/sepsis. In Latin America, there are 32 Intensive Care Units above 2500 m above sea level. Arterial blood gases at altitude are affected by changes in barometric pressure. The analysis of their values provides very useful information for the management of obstetric emergencies at very high altitude, especially respiratory and metabolic pathologies.

Trends in maternal ICU admissions at a quaternary centre in Montreal, Canada, and impact of maternal age on critical care outcomes

Background

Advancing maternal age is increasingly prevalent and is associated with severe maternal morbidity often requiring intensive care unit (ICU) admission.

Objectives

To describe maternal ICU admissions at a quaternary care hospital in Montreal, Canada, and evaluate the association between maternal age and composite of: need for invasive interventions, ICU stay > 48 h, or maternal death.

Methods

Chart review of ICU admissions during pregnancy/postpartum (2006-2016); logistic regressions to evaluate the impact of age on outcomes.

Results

With 5.1 ICU admissions per 1000 deliveries, we included 187 women (mean age 32 ± 6.3 years; 20 (10.7%) ≥ 40 years). The composite outcome occurred in 105 (56.2%) patients; there were two maternal deaths. Age ≥ 40 years increased the odds of invasive interventions (OR 4.03; 95% confidence interval [CI] 1.15-14.1) but not of the composite outcome (OR 2.30; 95% CI 0.66-8.02).

Conclusion

Peripartum women aged ≥ 40 years had worse outcomes in ICU, with an increased need for invasive interventions.

Preparedness for severe maternal morbidity in European hospitals: The MaCriCare study

PURPOSE

To evaluate obstetric units (OUs) and intensive care units (ICUs) preparedness for severe maternal morbidity (SMM).

METHODS

From September 2021 to January 2022, an international multicentre cross-sectional study surveyed OUs in 26 WHO Europe Region countries. We assessed modified early obstetric warning score usage (MEOWS), approaches to four SMM clinical scenarios, invasive monitoring availability in OUs, and access to high-dependency units (HDUs) and onsite ICUs. Within ICUs, we examined the availability of trained staff, response to obstetric emergencies, leadership, and data collection.

RESULTS

1133 responses were evaluated. MEOWS use was 34.5%. Non-obstetric early warning scores were being used. 21.4% (242) of OUs provided invasive monitoring in the OU. A quarter lacked access to onsite HDU beds. In cases of SMM, up to 13.8% of all OUs indicated the need for transfer to another hospital. The transfer rate was highest (74.0%) in small units. 81.9% of centers provided onsite ICU facilities to obstetric patients. Over 90% of the onsite ICUs provided daily specialist obstetric reviews but lacked immediate access to key resources: 3.4% - uterotonic drugs, 7.5% - neonatal resuscitation equipment, 9.2% - neonatal resuscitation team, 11.4% - perimortem cesarean section equipment. 41.2% reported obstetric data to a national database.

CONCLUSION

Gaps in provision exist for obstetric patients with SMM in Europe, potentially compromising patient safety and experience. MEOWS use in OUs was low, while access to invasive monitoring and onsite HDU and ICU facilities was variable. ICUs frequently lacked resources and did not universally collect obstetric data for quality control.

Imaging of Antepartum and Postpartum Hemorrhage

Severe obstetric hemorrhage is a leading cause of maternal mortality and morbidity worldwide. Major hemorrhage in the antepartum period presents potential risks for both the mother and the fetus. Similarly, postpartum hemorrhage (PPH) accounts for up to a quarter of maternal deaths worldwide. Potential causes of severe antepartum hemorrhage that radiologists should be familiar with include placental abruption, placenta previa, placenta accreta spectrum disorders, and vasa previa. Common causes of PPH that the authors discuss include uterine atony, puerperal genital hematomas, uterine rupture and dehiscence, retained products of conception, and vascular anomalies. Bleeding complications unique to or most frequently encountered after cesarean delivery are also enumerated, including entities such as bladder flap hematomas, rectus sheath and subfascial hemorrhage, and infectious complications of endometritis and uterine dehiscence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Javitt and Madrazo in this issue.

Lung Protective Ventilation during Pregnancy: An Observational Cohort Study

Objectives  We sought to describe characteristics of mechanically ventilated pregnant patients, evaluate utilization of low-tidal-volume ventilation (LTVV) and high-tidal-volume ventilation (HTVV) by trimester, and describe maternal and fetal outcomes by ventilation strategy. Study Design  This is a retrospective cohort study of pregnant women with mechanical ventilation for greater than 24 hours between July 2012 and August 2020 at a tertiary care academic medical center. We defined LTVV as average daily tidal volume 8 mL/kg of less of predicted body weight, and HTVV as greater than 8 mL/kg. We examined demographic characteristics, maternal and fetal characteristics, and outcomes by ventilation strategy. Results  We identified 52 ventilated pregnant women, 43 had LTVV, and 9 had HTVV. Acute respiratory distress syndrome occurred in 73% ( N  = 38) of patients, and infection was a common indication for ventilation ( N  = 33, 63%). Patients had LTVV more often than HTVV in all trimesters. Obstetric complications occurred frequently, 21% ( N  = 11) experienced preeclampsia or eclampsia, and among 43 patients with available delivery data, 60% delivered preterm ( N  = 26) and 16% had fetal demise ( N  = 7). Conclusion  LTVV was utilized more often than HTVV among pregnant women in all trimesters. There was a high prevalence of maternal and fetal morbidity and fetal mortality among our cohort. Key Points Our center utilized low tidal more often than high-tidal-volume ventilation during all trimesters of pregnancy.Prone positioning can be performed at advanced gestations.Infection is a common cause of antepartum ventilation.

Driving pressure in mechanical ventilation: A review

Driving pressure (∆P) is a core therapeutic component of mechanical ventilation (MV). Varying levels of ∆P have been employed during MV depending on the type of underlying pathology and severity of injury. However, ∆P levels have also been shown to closely impact hard endpoints such as mortality. Considering this, conducting an in-depth review of ∆P as a unique, outcome-impacting therapeutic modality is extremely important. There is a need to understand the subtleties involved in making sure ∆P levels are optimized to enhance outcomes and minimize harm. We performed this narrative review to further explore the various uses of ∆P, the different parameters that can affect its use, and how outcomes vary in different patient populations at different pressure levels. To better utilize ∆P in MV-requiring patients, additional large-scale clinical studies are needed.

Maternal high-care and intensive care units in low- and middle-income countries

Despite notable advancements in minimizing maternal mortality during recent decades, a pronounced disparity persists between high-income nations and low-to middle-income countries (LMICs), particularly in intensive and high-care for pregnant and postpartum individuals. This divergence is multifactorial and influenced by factors such as the availability and accessibility of community-based maternity healthcare services, the quality of preventive care, timeliness in accessing hospital or critical care, resource availability, and facilities equipped for advanced interventions. Complications from various conditions, including human immunodeficiency virus (HIV), unsafe abortions, puerperal sepsis, and, notably, the COVID-19 pandemic, intensify the complexity of these challenges. In confronting these challenges and deliberating on potential solutions, we hope to contribute to the ongoing discourse around maternal healthcare in LMICs, ultimately striving toward an equitable health landscape where every mother, regardless of geographic location or socioeconomic status, has access to the care they require and deserve. The use of traditional and innovative methods to achieve adequate knowledge, appropriate skills, location of applicable resources, and strong leadership is essential. By implementing and enhancing these strategies, limited-resource settings can optimize the available resources to promptly recognize the severity of illness in obstetric individuals, ensuring timely and appropriate interventions for mothers and children. Additionally, strategies that could significantly improve the situation include increased investment in healthcare infrastructure, effective resource management, enhanced supply chain efficiency, and the development and use of low-cost, high-quality equipment. Through targeted investments, innovations, efficient resource management, and international cooperation, it is possible to ensure that every maternal high-care and ICU unit, regardless of geographical location or socioeconomic status, has access to high-quality critical care to provide life-saving care.

Incidence of Interstitial Alveolar Syndrome on Point-of-Care Lung Ultrasonography in Pre-eclamptic Women With Severe Features: A Prospective Observational Study

BACKGROUND

Lung interstitial edema is a clinically silent pathology that develops before overt pulmonary edema among pre-eclamptic women with severe features. Point-of-care lung ultrasonography (LUS) has been suggested as an accessible bedside tool that may identify lung interstitial edema before developing clinical signs and symptoms. Thus, we planned to use bedside LUS as a diagnostic tool in admitted pre-eclamptic women with severe features, with the aim of identifying alveolar-interstitial fluid, seen as B-lines. Our primary objective was to assess the incidence of interstitial alveolar syndrome on lung ultrasonography.

METHODS

We conducted a prospective, single-center, observational study on parturients with pre-eclampsia with severe features over a period of 15 months. LUS in 4 intercostal spaces (ICS) was performed on all eligible patients. The number of single or confluent B-lines in each space was recorded by an independent observer. A scoring system was used to grade the lung fluid content based on the number of single and confluent B-lines per ICS, with scores ranging from 0 to 32 (low, 0-10; moderate, 11-20; and high, 21+). The incidence of B-lines at admission and before and after delivery was calculated. In addition, bedside 2D echocardiography was performed to assess left ventricular systolic and diastolic function. Any correlation between presence of B-lines on LUS and blood pressure, clinical symptoms, or echocardiography findings was assessed.

RESULTS

Seventy patients were enrolled in the study. On LUS, B-lines were seen in 64.3% patients at admission (45/70 vs 25/70 without B-lines; P = .02), 65.7% patients before delivery (46/70 vs 24/70 without B-lines; P = .01), and 58.6% patients 24 hours postpartum (41/70 versus 29/70 without B-lines; P = .15). Nearly all patients (94.3%) exhibited low to moderate severity of pulmonary fluid burden at admission. Echocardiography revealed diastolic dysfunction in 47.1% (n = 33/70) patients with associated B-lines in the majority (n = 32/33). The total B-line score and E/e' ratio among patients with diastolic dysfunction was found to be strongly correlated (r = 0.848; P < .001). All pre-eclamptic women with presence of breathlessness (11/11; 100%) and facial puffiness (16/16; 100%) on admission had B-lines on LUS.

CONCLUSIONS

We conclude that ultrasonographic pulmonary interstitial syndrome is present in more than half of the women with pre-eclampsia with severe features and correlates with diastolic dysfunction, high blood pressure records, and acute-onset breathlessness.

Medical Emergencies in the Pregnant Patient

This review article provides a comprehensive overview of common medical emergencies that can occur in pregnant patients. We summarize the key diagnostic and management steps for each emergency to assist health care professionals in identifying and treating these potentially life-threatening conditions. The medical emergencies discussed in this article include postpartum hemorrhage; hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome; acute fatty liver of pregnancy; amniotic fluid embolism; pulmonary embolism; acute respiratory distress syndrome; and shock. Each condition is described in detail, with a focus on the clinical presentation, diagnostic workup, and treatment options. The information presented in this review article is based on current best practices and guidelines from leading medical organizations. We hope this article will serve as a valuable resource for health care professionals who care for pregnant patients and help improve outcomes for these patients in emergency situations.

Social determinants and exposure to intimate partner violence in women with severe acute maternal morbidity in the intensive care unit: a systematic review

BACKGROUND

Studying severe acute maternal morbidity in the intensive care unit improves our understanding of potential factors affecting maternal health.

AIM

To review evidence on maternal exposure to intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit.

METHODS

The protocol for this review was registered in PROSPERO (registration number CRD42016037492). A systematic search was performed in MEDLINE, CINAHL, ProQuest, LILACS and SciELO using the search terms "intensive care unit", "intensive care", "critical care" and "critically ill" in combination with "intimate partner violence", "social determinants of health", "severe acute maternal morbidity", pregnancy, postpartum and other similar terms. Eligible studies were (i) quantitative, (ii) published in English and Spanish, (iii) from 2000 to 2021, (iv) with data related to intimate partner violence and/or social determinants of health, and (v) investigating severe acute maternal morbidity (maternity patients treated in the intensive care unit during pregnancy, childbirth or within 42 days of pregnancy termination). Of 52,866 studies initially identified, 1087 full texts were assessed and 156 studies included. Studies were independently assessed by two reviewers for screening, revision, quality assessment and abstracted data. Studies were categorised into high/middle/low-income countries and summarised data were presented using a narrative description, due to heterogenic data as: (i) exposure to intimate partner violence and (ii) social determinants of health.

RESULTS

One study assessed intimate partner violence among mothers with severe acute maternal morbidity in the intensive care unit and found that women exposed to intimate partner violence before and during pregnancy had a nearly four-fold risk of severe acute maternal morbidity requiring ICU admission. Few social determinants of health other than age were reported in most studies.

CONCLUSION

This review identified a significant gap in knowledge concerning intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit, which is essential to better understand the complete picture of the maternal morbidity spectrum and reduce maternal mortality.

Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care

Sepsis in obstetric care is one of the leading causes of maternal death in the United States, with Black, Asian/Pacific Islander, and American Indian/Alaska Native obstetric patients experiencing sepsis at disproportionately higher rates. State maternal mortality review committees have determined that deaths are preventable much of the time and are caused by delays in recognition, treatment, and escalation of care. The "Sepsis in Obstetric Care" patient safety bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people by preventing infection and recognizing and treating infection early to prevent progression to sepsis. This is one of several core patient safety bundles developed by AIM (the Alliance for Innovation on Maternal Health) to provide condition- or event-specific clinical practices that should be implemented in all appropriate care settings. As with other bundles developed by AIM, the "Sepsis in Obstetric Care" patient safety bundle is organized into five domains: Readiness, Recognition and Prevention, Response, Reporting and Systems Learning, and Respectful, Equitable, and Supportive Care. The Respectful, Equitable, and Supportive Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into the elements of each domain.

Peripartum Maternal Admission to the Intensive Care Unit: An Observational Study over a 15-Year Period at a Tertiary Center in Austria

Peripartum maternal admission to the intensive care unit is challenging for anesthesiologists, obstetricians, and all personnel involved. An understanding of altered maternal physiology, fetal considerations, and acute peripartum emergencies is required to ensure adequate maternal and neonatal outcomes. In this study, we analyzed data of peripartum maternal admissions to the intensive care unit at our large tertiary referral center in order to define trends and changes over time. This study retrospectively analyzed maternal morbidity, admission diagnoses, treatments, and outcomes of women with peripartum admission to the intensive care unit at our tertiary care center over a 15-year period. We found that patient characteristics and admission diagnoses remained remarkably consistent over the observational period; however, there was a significant increase in postpartum hemorrhage (r = 0.200, p < 0.001) and cesarean hysterectomy (r = 0.117, p = 0.027) over time. Moreover, we found a reduction in preterm births (r = -0.154, p = 0.004) and a decreased peripartum neonatal intensive care unit admission rate (r = -0.153, p = 0.006) among women who were transferred to the intensive care unit. Based on our long-term observational data, there is consistent need for intensive care in obstetrics due to a small number of different etiologies. Specialized training for the predominant diagnoses involved as well as multidisciplinary care of the affected patients are both warranted.

Obstetric admission to intensive care units in Japan: a cohort study using the Japanese Intensive care PAtient Database

PURPOSE

This study aimed to describe the epidemiology and annual trends of obstetric patients using a multicenter intensive care database.

METHODS

This multicenter, retrospective cohort study used the Japanese Intensive care PAtient Database (JIPAD). We included obstetric patients registered in the JIPAD between 2015 and 2020. We investigated the proportion of obstetric patients among all patients in the intensive care unit (ICU). We also described the characteristics, procedures, and outcomes of obstetric patients. In addition, the annual trends were examined by nonparametric tests for trends.

RESULTS

Of the 184,705 patients enrolled in the JIPAD, 750 (0.41%) were obstetric patients from 61 facilities. The median age was 34 years, the number of post-emergency surgeries was 450 (60.0%), and the median APACHE III score was 36. Mechanical ventilation was the most common procedure performed in 247 (32.9%) patients. There were five (0.7%) in-hospital deaths. The proportion of obstetric patients in the ICU did not change between 2015 and 2020 (P for trend = 0.32). However, there was a trend for a significant decrease in the severity of illness and length of hospital stay on an annual basis between 2015 and 2020. Most patients were admitted to the ICU because of a pregnancy-related disorder postoperatively.

CONCLUSION

The proportion of obstetric patients was 0.41% of all ICU admissions. The proportion of obstetric patients admitted to the ICU did not change from 2015 to 2020, but the patients' severity of illness and length of hospital stay significantly decreased over time.

Trend and risk Factors for Severe Peripartum Maternal morbidity - a population-based Cohort Study

OBJECTIVES

While the rates of maternal mortality in developed countries have remained low in recent years, rates of severe maternal morbidity (SMM) are still increasing in high income countries. As a result, SMM is currently used as a measure of maternity care level. The aim of this study was to investigate the prevalence and risk factors of SMM surrounding childbirth.

METHODS

A nested case-control study was performed between the years 2013-2018. SMM was defined as peripartum hospitalization involving intensive care unit (ICU). A comparison was conducted between parturient with SMM to those without, randomly matched for delivery mode and date of birth in a 1:1 ratio. Multivariable logistic regression models were used to evaluate the independent association between SMM and different maternal and pregnancy characteristics.

RESULTS

During the study period, 96,017 live births took place, of which 144 (1.5 per 1,000 live births-0.15%) involved SMM with ICU admissions. Parturient with SMM were more likely to have a history of 2 or more pregnancy losses (18.2% vs. 8.3%, p = 0.004), deliver preterm (48.9% vs. 8.8%, p < 0.001), and suffer from placenta previa (11.9% vs. 1.5%, p < 0.001), and/or placenta accreta (9.7% vs. 1.5%, p = 0.003). Several significant and independent risk factors for SMM were noted in the multivariable regression models: preterm delivery, history of ≥ 2 pregnancy losses, grand-multiparity, Jewish ethnicity, and abnormal placentation (previa or accreta).

CONCLUSIONS FOR PRACTICE

SMM rates in our cohort were lower than reported in developed countries. An independent association exists between peripartum maternal ICU admissions and several demographic and clinical risk factors, including preterm birth and abnormal placentation.

Patient Sociodemographics and Comorbidities and Birth Hospital Characteristics Associated With Postpartum Emergency Department Care

IMPORTANCE

Postpartum emergency department (ED) visits may indicate poor access to care and risk for maternal morbidity.

OBJECTIVES

To identify patient and hospital characteristics associated with postpartum ED visit rates.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data from the 2014 to 2016 New York State Inpatient Database and State Emergency Department Database. All obstetric discharges from acute care hospitals in New York State from January 1, 2014, through November 15, 2016, were included. Obstetric discharges in the inpatient database were linked to subsequent ED visits by the same patient in the ED database. Data were analyzed from February 2020 to August 2022.

EXPOSURES

Patient characteristics assessed included age, race, insurance, home zip code income quartile, Charlson Comorbidity Index score, and obstetric risk factors. Hospital characteristics assessed included safety net status, teaching status, and status as a hospital disproportionally serving racial and ethnic minority populations.

MAIN OUTCOMES AND MEASURES

The primary outcome was any ED visit within 42 days of obstetric discharge. Multilevel logistic regression with 2-level nested mixed effects was used to account for patient and hospital characteristics and hospital-level clustering.

RESULTS

Of 608 559 obstetric discharges, 35 299 (5.8%) were associated with an ED visit within 42 days. The median (IQR) birth hospital postpartum ED visit rate was 6.3% (4.6%-8.7%). The mean (SD) age was 28.4 (9.1) years, 53 006 (8.7%) were Asian patients, 90 675 (14.9%) were Black patients, 101 812 (16.7%) were Hispanic patients, and 275 860 (45.3%) were White patients; 292 991 (48%) were insured by Medicaid, and 290 526 (47.7%) had private insurance. Asian patients had the lowest postpartum ED visit rates (2118 ED visits after 53 006 births by Asian patients [3.99%]), and Black patients had the highest postpartum ED visit rates (8306 ED visits after 90 675 births by Black patients [9.15%]). Odds of postpartum ED visits were greater for Black patients (odds ratio [OR], 1.31; 95% CI, 1.26-1.35; P < .001) and Hispanic patients (OR, 1.19; 95% CI, 1.15-1.24; P < .001) relative to White patients; those with Medicare (OR, 1.55; 95% CI, 1.39-1.72; P < .001), Medicaid (OR, 1.37; 95% CI, 1.34-1.41; P < .001), or self-pay insurance (OR, 1.50; 95% CI, 1.41-1.59; P < .001) relative to commercial insurance; births that occurred at safety net hospitals (OR, 1.43; 95% CI, 1.37-1.51; P < .001) and hospitals disproportionately serving racial and ethnic minority populations (OR, 1.14; 95% CI, 1.08-1.20; P < .001); and births that occurred at hospitals with fewer than 500 births per year (OR, 1.25; 95% CI, 1.14-1.39; P < .001) relative to those with more than 2000 annual births. Adjusted odds of postpartum ED visits were lower after birth at teaching hospitals (OR,  0.82; 95% CI, 0.74-0.91; P < .001) and metropolitan hospitals (OR, 0.74; 95% CI, 0.65-0.85; P < .001).

CONCLUSIONS AND RELEVANCE

This cohort study found that Black and Hispanic patients experienced higher adjusted odds of postpartum ED visits across all hospital types, particularly at safety net hospitals and those disproportionately serving racial and ethnic minority populations . These findings support the urgent need to mitigate structural racism underlying maternal health disparities.

Non-Cardiogenic Pulmonary Edema Due to Administration of Atosiban

We report the case of a pregnant woman, treated with atosiban for premature labor, who developed non-cardiogenic pulmonary edema. She corresponded initially to oxygen supplementation and furosemide administration to induce diuresis but the onset of preterm contractions combined with aggravation of respiratory failure led the patient to a cesarean section, and subsequently to the intensive care unit where she remained intubated for 24 hours. In this case report, we emphasize the importance of distinguishing between two types of pulmonary edema: cardiogenic and non-cardiogenic. The instant separation between these two categories, most of the time with transthoracic echocardiography while the patient is on early support of ventilation, increases the optimum outcome for the patient.

Acute Respiratory Distress Syndrome in Pregnancy: Updates in Principles and Practice

Acute respiratory failure occurs in 0.05% to 0.3% of pregnancies and is precipitated by pulmonary and nonpulmonary insults. Acute respiratory distress syndrome (ARDS) is the rapid onset of hypoxemic respiratory failure associated with bilateral pulmonary opacities on chest imaging attributed to noncardiogenic pulmonary edema. The pathophysiological features of ARDS include hypoxemia, diminished lung volumes, and decreased lung compliance. While there is a paucity of data concerning ARDS in the pregnant individual, management principles do not vary significantly between pregnant and nonpregnant patients. The following review will discuss the diagnosis and management of the pregnant patient with ARDS.

Extracorporeal membrane oxygenation for COVID-19-related acute respiratory distress syndrome: a narrative review

A growing body of evidence supports the use of extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) refractory to maximal medical therapy. ARDS may develop in a proportion of patients hospitalized for coronavirus disease 2019 (COVID-19) and ECMO may be used to manage patients refractory to maximal medical therapy to mitigate the risk of ventilator-induced lung injury and provide lung rest while awaiting recovery. The mortality of COVID-19-related ARDS was variously reassessed during the pandemic. Veno-venous (VV) ECMO was the default choice to manage refractory respiratory failure; however, with concomitant severe right ventricular dysfunction, venoarterial (VA) ECMO or mechanical right ventricular assist devices with extracorporeal gas exchange (Oxy-RVAD) were also considered. ECMO has also been used to manage special populations such as pregnant women, pediatric patients affected by severe forms of COVID-19, and, in cases with persistent and seemingly irreversible respiratory failure, as a bridge to successful lung transplantation. In this narrative review, we outline and summarize the most recent evidence that has emerged on ECMO use in different patient populations with COVID-19-related ARDS.

Evaluation of critically ill obstetric patients treated in an intensive care unit during the COVID-19 pandemic

BACKGROUND

Although obstetric morbidity and mortality have decreased recently, rates are still high enough to constitute a significant health problem. With the COVID-19 pandemic, many obstetric patients have required treatment in intensive care units (ICU).

OBJECTIVES

Evaluate critical obstetric patients who were treated in an ICU for COVID-19 and followed up for 90 days.

DESIGN

Medical record review SETTING: Intensıve care unit PATİENTS AND METHODS: Obstetric patients admitted to the ICU between 15 March 2020 and 15 March 2022 and followed up for at least 90 days were evaluated retrospectively. Patients with and without COVID-19 were compared by gestational week, indications, comorbidities, length of stay in the hospital and ICU, requirement for mechanical ventilation, blood transfusion, renal replacement therapy (RRT), plasmapheresis, ICU scores, and mortality.

MAIN OUTCOME MEASURES

Clinical outcomes and mortality.

SAMPLE SIZE AND CHARACTERISTICS

102 patients with a mean (SD) maternal age of 29.1 (6.3) years, and median (IQR) length of gestation of 35.0 (7.8) weeks.

RESULTS

About 30% (n=31) of the patients were positive for COVID-19. Most (87.2%) were cesarean deliveries; 4.9% vaginal (8.7% did not deliver). COVID-19, eclampsia/preeclampsia, and postpartum hemorrhage were the most common ICU indications. While the 28-day mortality was 19.3% (n=6) in the COVID-19 group, it was 1.4% (n=1) in the non-COVID-19 group (P<.001). The gestational period was significantly shorter in the COVID-19 group (P=.01) while the duration of stay in ICU (P<.001) and mechanical ventilation (P=.03), lactate (P=.002), blood transfusions (P=.001), plasmapheresis requirements (P=.02), and 28-day mortality were significantly higher (P<.001). APACHE-2 scores (P=.007), duration of stay in ICU (P<.001) and mechanical ventilation (P<.001), RRT (P=.007), and plasmapheresis requirements (P=.005) were significantly higher in patients who died than in those who were discharged.

CONCLUSION

The most common indication for ICU admission was COVID-19. The APACHE-2 scoring was helpful in predicting mortality. We think multicenter studies with larger sample sizes are needed for COVID-19 obstetric patients. In addition to greater mortality and morbidity, the infection may affect newborn outcomes by causing premature birth.

LIMITATIONS

Retrospectıve, single-center, small population size.

CONFLICT OF INTEREST

None.

Obstetric Emergencies

Human gestation and birthing result in many deviations from usual physiology that are nonetheless normal to be seen. However, on occasion, certain complications in the obstetric patient can be life-threatening to both mother and fetus. Timely recognition of these disorders and allocation of the appropriate resources are especially important. These conditions often require an intensive care unit admission for closer monitoring and supportive care. They can affect an array of physiological systems and can lead to significant morbidity. Such complications are discussed in greater detail in this article.

Obstetric Disorders and Critical Illness

In this article, we discuss some of the more common obstetric-related conditions that can lead to critical illness and require management in an ICU. These include the hypertensive disorders of pregnancy, postpartum hemorrhage, hemolysis, elevated liver enzymes, and low platelet syndrome, acute fatty liver of pregnancy, amniotic fluid embolism, and peripartum cardiomyopathy. We also discuss pulmonary embolism and Covid-19. Despite not being specific to obstetric patients, pulmonary embolism is a common, life-threatening diagnosis in pregnancy with particular risks and management aspects. Covid-19 does not seem to occur with higher frequency in pregnant women, but it leads to higher rates of ICU admissions and mechanical ventilation in pregnant women than in their nonpregnant peers. Its prevalence during our current global pandemic makes it important to discuss in this article. We provide a basis for critical care physicians to be engaged in informed conversations and management in a multidisciplinary manner with other relevant providers in the care of critically ill pregnant and postpartum women.

Obstetrics mortality and associated factors in intensive care unit of Addis Ababa public hospital in, 2020/21: A hospital based case control study

Background

In low-income nations like Ethiopia, the rate of obstetric death in intensive care units is significant. The indications of admission are Preeclampsia/Eclampsia, postpartum hemorrhage, and puerperal sepsis but, patient outcomes subsequent to intensive care unit admission are sparse. The aim of this study is to assess factors associated with obstetrics mortality in Intensive Care unit.

Methods

A hospital based unmatched case control study was conducted on obstetrics patients admitted to Addis Ababa Public hospital's intensive care unit from October 2018 to November 2020. Multivariable logistic regression analysis was done; Odds Ratio and Confidence Interval (OR and 95% CI) were computed using SPSS version 26. P value < 0.05 was taken as statistically significant.

Result

Obstetrics mortality in intensive care unit was high and accounts 27% from the total intensive care unit admission. Severe pre-eclampsia AOR: 6.33; 95% CI: 2.25–17.79, puerperal sepsis AOR: 4.51; 95% CI: 1.68–12.15, age ≥35 years AOR: 4.09; 95% CI: 1.42–11.77, absence of antenatal care: AOR: 3.74; 95% CI: 1.03–13.5, maternal coexisting diseases AOR: 5.2; 95% CI: 2.22–12.16, and severely decrease of consciousness at admission AOR: 3.78; 95% CI: 1.21–11.79 were significantly associated with obstetrics mortality in Addis Ababa Public Hospitals intensive care unit.

Conclusion

and Recommendation: Maternal age ≥35 years, loss of antenatal care, puerperal sepsis, severe pre-eclampsia, pre-existing medical comorbidities and severe decrease level of consciousness during ICU admission were the most significant factors associated with obstetrics mortality. It is recommended that all pregnant women should have antenatal care so that preeclampsia and maternal comorbidities will be early diagnosed and treated.

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Obstetrics mortality in intensive care unit (ICU) is high in low-income countries.

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The indications of admission are Preeclampsia/Eclampsia, postpartum hemorrhage, and puerperal sepsis.

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Obstetrics mortality in intensive care unit was high and accounts 27% from the total intensive care unit admission.

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The aim of this study is to assess factors associated with obstetrics mortality in ICU.

Analysis of the structural adequacy of maternity hospitals in Piauí, Brazil, 2018-2019

Abstract Objectives: to evaluate the structure and adequacy of maternal healthcare facilities in Piauí. Methods: cross-sectional study in 26 hospitals with more than 200 births/year between 2018-2019. The structure was assessed by direct observation and interview with manager, in four domains: physical aspects, human resources, equipment, and drugs. Fisher’s chi-square/exact tests were used to assess differences in adequacy of structure. Results: only 46.2% of the maternal healthcare facilities had pre-delivery, parturition and immediate post-partum room. Pediatricians (73.1%) and anesthesiologists (61.5%) were the least present professionals on-duty regime. Regarding drugs, magnesium sulfate and oxytocin were observed in 76.9% of hospitals. Overall adequacy was 23.1%, being higher in maternal healthcare facilities in the capital (p=0.034) and in private ones (p=0.031). Conclusions: Data show inequalities in the structure of maternity hospitals of the state. The absence of health professionals, essential drugs, and appropriate physical structure can expose women and newborns to unnecessary and avoidable risks.

Factors Affecting ICU Stay and Length of Stay in the ICU in Patients with HELLP Syndrome in a Tertiary Referral Hospital

Objective

The study aimed to compare patients with HELLP syndrome who require intensive care and who do not require intensive care and evaluate the factors affecting the length of stay in the intensive care unit.

Methods

Patients were divided into two groups as follows: requiring intensive care (group 1) and not requiring intensive care (group 2). The data of both groups were compared in terms of demographic characteristics, transfusion amounts, length of stay in the intensive care unit, maternal complications, and mortality.

Results

14032 births in a tertiary center between 2011 and 2018 were evaluated in this study. During the study period, 342 patients were diagnosed with HELLP, and 32 (9.4%) of these were followed up in the intensive care unit. The length of stay in the intensive care unit was determined as 8.1 (7.2) days on average. Fresh frozen plasma, erythrocyte suspension, apheresis, and random thrombocyte transfusion were observed to be significantly more in group 1 patients. In the regression analysis, the most effective factor was found to be erythrocyte suspension and the length of stay in the intensive care unit was significantly longer in patients who had erythrocyte suspension transfusion. The receiver operating characteristic curve showed that the area under the curve value for erythrocyte transfusion was 70.6%. When the cutoff value of erythrocyte suspension was 450 (95% CI: 365–681) ml, the sensitivity was 43.8% and the specificity was 91.6%.

Conclusion

We think that physicians should be careful that maternal morbidity and mortality may increase as the need for erythrocyte suspension transfusion increases in patients with HELLP syndrome. Minimum transfusion to hemodynamically stable patients can be more suitable in terms of morbidity and mortality in managing patients with HELLP syndrome requiring erythrocyte suspension transfusion. Precautions and measures should be taken in this regard.

Indications and diagnosis-specific features of maternal and neonatal peripartum intensive care unit admissions: A retrospective study

BACKGROUND

Although peripartum intensive care unit admission indications are well-reported, clinical and laboratory details rarely are. We described admission indications and categorised laboratory values and vital signs according to admission diagnosis.

METHODS

Retrospective Institutional Review Board approved study. We identified intensive care unit admission diagnosis, laboratory values and vital signs from patient charts. Groups were compared according to admission diagnoses. Data were analysed using descriptive statistics.

RESULTS

We included 91 general intensive care unit admissions among 56,865 deliveries (2011-2015) with complete data. The most common admission diagnosis was postpartum haemorrhage followed by hypertensive diseases of pregnancy and respiratory complications. Women with postpartum haemorrhage had lower mean (standard deviation) platelet counts (120.2 (45.8) vs. 181.2 (109.9), p = .003) and temperatures (35.7 (1.1) vs. 36.5 (1.2), p = .002). Women with hypertensive diseases of pregnancy had higher mean (standard deviation) blood pressures (systolic 150.4 (29.1) vs. 127.4 (21.0), p = .013, diastolic 100.3 (18.7) vs. 76.1 (16.1), p = .001), creatinine (1.1 (0.6) vs. 0.8 (0.3), p = .003), urea (14.6 (7.7) vs. 10.5 (4.7), p = .005) and liver enzymes, including aspartate transaminase (258.4 (297.0) vs. 41.4 (42.9), p = .000), alanine transaminase (184.4 (199.2) vs. 35.1 (75.9), p = .000), and alkaline phosphatase (166.6 (112.6) vs. 96.0 (60.0), p = .006). Women with respiratory complications had lower mean (standard deviation) oxygen saturations (93.7 (6.1) vs. 98.0 (2.6), p = .000), and higher mean (standard deviation) temperatures (37.1 (0.8) vs. 36.0 (1.2), p = .001).

CONCLUSIONS

We report differences in laboratory values and vital signs, according to intensive care unit admission diagnosis. Recognising these differences might help individualise patient assessment and care.

Prognosticating Fetomaternal ICU Outcomes

Although no scoring system is as yet fully validated for predicting maternal outcomes in critically ill obstetric patients, prognostication may be done objectively using severity predicting models. General critical care scoring systems which have been studied in obstetric patients are outcome prediction models (Acute Physiology and Chronic Health Evaluation [APACHE] I-IV, Simplified Acute Physiology Score [SAPS] I-III, Mortality Probability Model [MPM] I-IV) and organ dysfunction scores (Multiple Organ Dysfunction Score [MODS], Logistic Organ Dysfunction Score [LODS], Sequential Organ Failure Assessment [SOFA]). General critical care scoring systems may overpredict mortality rates in obstetric patients secondary to an altered physiology of organ systems during pregnancy. Obstetric prediction models were developed keeping in mind the physiological characteristics of obstetric population. They are Modified Early Obstetric Warning System (MEOWS), Obstetric Early Warning Score (OEWS), Maternal Early Warning Trigger (MEWT), and disease-specific obstetric scoring systems. The APACHE II model and MPM II are most often used scoring systems for predicting maternal mortality. The SOFA model is the best predictive model for sepsis in obstetrics. APACHE II and SAPS are more useful for nonobstetric population. Recent studies have also underscored the applicability of the OEWS in intensive care unit (ICU) settings with results comparable to the more elaborate APACHE II and SOFA scores. The Early Warning System helps in identifying acutely deteriorating pregnant and postpartum women in non-ICU settings who may require critical care. Fetal outcomes are largely dependent upon maternal outcomes. Prognostic systems applied to mothers may help in estimation of perinatal mortality and morbidity.

A ten-year review of indications and outcomes of obstetric admissions to an intensive care unit in a low-resource country

Introduction

Obstetric intensive care unit admission (ICU) suggests severe morbidity. However, there is no available data on the subject in Ghana. This retrospective review was conducted to determine the indications for obstetric ICU admission, their outcomes and factors influencing these outcomes to aid continuous quality improvement in obstetric care.

Methods

This was a retrospective review conducted in a tertiary hospital in Ghana. Data on participant characteristics including age and whether participant was intubated were collected from patient records for all obstetric ICU admissions from 1^st January 2010 to 31^st December 2019. Descriptive statistics were presented as frequencies, proportions and charts. Hazard ratios were generated for relations between obstetric ICU admission outcome and participant characteristics. A p-value <0.05 was deemed statistically significant.

Results

There were 443 obstetric ICU admissions over the review period making up 25.7% of all ICU admissions. The commonest indications for obstetric ICU admissions were hypertensive disorders of pregnancy (70.4%, n = 312/443), hemorrhage (14.4%, n = 64/443) and sepsis (9.3%, n = 41/443). The case fatality rates for hypertension, hemorrhage, and sepsis were 17.6%, 37.5%, and 63.4% respectively. The obstetric ICU mortality rate was 26% (115/443) over the review period. Age ≥25 years and a need for mechanical ventilation carried increased mortality risks following ICU admission while surgery in the index pregnancy was associated with a reduced risk of death.

Conclusion

Hypertension, haemorrhage and sepsis are the leading indications for obstetric ICU admissions. Thus, preeclampsia screening and prevention, as well as intensifying antenatal education on the danger signs of pregnancy can minimize obstetric complications. The establishment of an obstetric HDU in CCTH and the strengthening of communication between specialists and the healthcare providers in the lower facilities, are also essential for improved pregnancy outcomes. Further studies are needed to better appreciate the wider issues underlying obstetric ICU admission outcomes.

Plain language summary

This was a review of the reasons for admitting severely-ill pregnant women and women who had delivered within the past 42 days to the intensive care unit (ICU), the admission outcomes and risk factors associated with ICU mortality in a tertiary hospital in a low-resource country. High blood pressure and its complications, bleeding and severe infections were observed as the three most significant reasons for ICU admissions in decreasing order of significance. Pre-existing medical conditions and those arising as a result of, or aggravated by pregnancy; obstructed labour and post-operative monitoring were the other reasons for ICU admission over the study period. Overall, 26% of the admitted patients died at the ICU and maternal age of at least 25 years and the need for intubation were identified as risk factors for ICU deaths. Attention must be paid to high blood pressure during pregnancy.

Escalating Care on Labor and Delivery

Maternal morbidity and mortality are rising due in part to the rising prevalence of chronic illness, socioeconomic and racial disparities, and advanced maternal age. Prevention of maternal adverse outcomes requires prompt escalation of care to facilities with appropriate capabilities including intensive care services. The development of obstetrical-specific risk assessment tools and protocolized care for the most common causes of maternal intensive care unit (ICU) admission has helped to reduce preventable complications. However, significant work remains to address barriers to the escalation of maternal care and minimize delays in appropriate management.

Postpartum Respiratory Depression

Postpartum respiratory depression is a complex, multifactorial issue that encompasses a patient's baseline preexisting conditions, certain pregnancy-specific conditions or complications, as well as the iatrogenic element of various medications given in the peripartum period. In this review, we discuss many of these factors including obesity, sleep-disordered breathing, chronic lung disease, neuromuscular disorders, opioids, preeclampsia, peripartum cardiomyopathy, postpartum hemorrhage, amniotic fluid embolism, sepsis, acute respiratory distress syndrome (ARDS), and medications such as analgesics, sedatives, anesthetics, and magnesium. Current recommendations for screening, treatment, and prevention are also discussed.

Predictability of adverse outcomes in hypertensive disorders of pregnancy: a multicenter prospective cohort study

OBJECTIVES

To explore variables associated with adverse maternal/fetal/neonatal outcomes among pregnant/postpartum patients admitted to ICU for hypertensive disorders of pregnancy (HDP).

METHODS

Multicenter, prospective, national cohort study.

RESULTS

Variables independently associated with maternal/fetal/neonatal mortality among 172 patients were as follows: Acute Physiology and Chronic Health Evaluation-II (APACHE-II)(OR1.20[1.06-1.35]), gestational age (OR0.698[0.59-0.82]) and aspartate aminotransferase (AST)(OR1.004[1.001-1.006]). Positive likelihood ratio for headache, epigastric pain, and visual disturbances to predict composite adverse outcomes were 1.23(1.16-1.30), 0.76(0.59-1.02), and 1.1(0.98-1.2), respectively.

CONCLUSIONS

Maternal/fetal mortality due to HDP was independently associated with severity of illness on admission, gestational age, and elevated AST. Accuracy of clinical symptoms to predict composite adverse outcomes was low.

A Detailed Review of Critical Care Considerations for the Pregnant Cardiac Patient

Maternal cardiovascular disease is a leading cause of maternal death worldwide and recently, maternal mortality has increased secondary to cardiovascular causes. Maternal admissions to critical care encompass 1%-2% of all critical care admissions, and although not common, the management of the critically ill pregnant patient is complex. Caring for the critically ill pregnant cardiac patient requires integration of pregnancy-associated physiologic changes, understanding pathophysiologic disease states unique to pregnancy, and a multidisciplinary approach to timing around delivery as well as antenatal and postpartum care. Herein we describe cardiorespiratory changes that occur during pregnancy and the differential diagnosis for cardiorespiratory failure in pregnancy. Cardiorespiratory diseases that are either associated or exacerbated by pregnancy are highlighted with emphasis on perturbations secondary to pregnancy and appropriate management strategies. Finally, we describe general management of the pregnant cardiac patient admitted to critical care.

Utilization and Outcomes of Extracorporeal Membrane Oxygenation in Obstetric Patients in the United States, 1999-2014: A Retrospective Cross-Sectional Study

BACKGROUND

Utilization of extracorporeal membrane oxygenation (ECMO) for adult critically ill patients is increasing, but data in obstetric cohorts are scant. This study analyzed ECMO utilization and maternal outcomes in obstetric patients in the United States.

METHODS

Data were abstracted from the 1999-2014 National Inpatient Sample (NIS), a 20% US national representative sample. ECMO hospitalizations (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 39.65) in patients ≥15 years of age were categorized into obstetric ECMO and nonobstetric ECMO. Obstetric patients included 4 categories: (1) loss or termination of pregnancy, (2) delivery (term or preterm), (3) postdelivery hospitalization, and (4) pregnancy without an obstetrical outcome. Possible underlying causes for obstetric ECMO were identified by analysis of ICD-9-CM codes in individual records. In-hospital death was abstracted from the NIS, and ECMO complications were identified using ICD-9-CM algorithms. Statistical significance in time-effect was assessed using weighted regression models.

RESULTS

During the 16-year study period, 20,454 adult ECMO cases were identified, of which 331 occurred in obstetric patients (1.6%; 95% confidence interval [CI], 1.4-1.8). Obstetric ECMO utilization rate was 4.7 per million obstetric discharges (95% CI, 4.2-5.2). The top 3 possible indications were sepsis (22.1%), cardiomyopathy (16.6%), and aspiration pneumonia (9.7%). Obstetric ECMO utilization rate increased significantly during the study period from 1.1 per million obstetric discharges in 1999-2002 (95% CI, 0.6-1.7) to 11.2 in 2011-2014 (95% CI, 9.6-12.9), corresponding to a 144.7% increase per 4-year period (95% CI, 115.3-178.1). Compared with nonobstetric ECMO, obstetric ECMO was associated with decreased in-hospital all-cause mortality (adjusted odds ratio [aOR] 0.78; 95% CI, 0.66-0.93). In-hospital all-cause mortality for obstetric ECMO decreased from 73.7% in 1999-2002 (95% CI, 48.8-90.8) to 31.9% in 2011-2014 (95% CI, 25.2-39.1), corresponding to a 26.1% decrease per 4-year period (95% CI, 10.1-39.3). Compared with nonobstetric ECMO, obstetric ECMO was associated with significantly increased risk of both venous thromboembolism without associated pulmonary embolism (aOR 1.83; 95% CI, 1.06-3.15) and of nontraumatic hemoperitoneum (aOR 4.32; 95% CI, 2.41-7.74).

CONCLUSIONS

During the study period, obstetric ECMO utilization has increased significantly and maternal prognosis improved.

Neurocritical care of the pregnant patient

INTRODUCTION

An estimated 0.1%-0.8% of obstetric patients require admission to an intensive care unit (ICU) during pregnancy or the puerperium. When neurologic emergencies occur in pregnancy, collaboration between the neurointensivist, obstetric anesthesiologist, and obstetrician is key in minimizing morbidity and mortality.

PRINCIPLES

Care of the critically ill pregnant patient mirrors that of the critically ill nonpregnant patient with some minor exceptions. Special care must be taken to consider the normal physiologic changes of pregnancy as well as possible fetal exposure to medical interventions. Timing and method of delivery must be carefully considered when caring for patients with neurologic emergencies. Common neurologic emergencies in pregnancy include hypertensive disorders of pregnancy, intracranial neoplasms, noneclamptic seizures, cerebrovascular disorders, and ventriculoperitoneal shunt malfunctions.

CONCLUSION

While neurologic emergencies in pregnancy are overall rare, when they do occur, they can be devastating. As in the nonpregnant population, prompt recognition and rapid intervention are crucial in optimizing patient outcomes. When neurologic emergencies occur in pregnancy, maternal and fetal care is optimized through a multidisciplinary care team.

Women of reproductive age in a tertiary intensive care unit: indications, outcome and the impact of pregnancy-a retrospective cohort study

Background

To evaluate the indications for admission and mortality rates of women of reproductive age admitted to a tertiary Intensive Care Unit (ICU) and to compare the outcomes of obstetric and non-obstetric admissions.

Methods

A retrospective cohort study was performed, including all women aged 17–41 years admitted to a level 3 ICU in the Netherlands, between January 1, 2000 and January 1, 2016. Primary outcome was indication for admission and mortality. Mortality, length of stay (LOS), need for mechanical ventilation and APACHE II score were compared between obstetric and non-obstetric admissions. The obstetric group was further analyzed for maternal and perinatal outcomes.

Results

3461 women (median age 32 years) were included, with an overall mortality rate of 13.3%. The obstetric group consisted of 265 women (7.7%). The non-obstetric group (n = 3196) was admitted most often for cardiovascular disease (19.6%), followed by oncologic disease (15%). Mortality was the highest in women with oncologic disease (23.9%). The obstetric group had lower mortality compared to the non-obstetric group (4.9% vs. 14%, p < 0.001), despite higher APACHE II score (14 vs. 11, p < 0.001) and a higher ventilation rate (47.9% vs. 39%, p = 0.004). Major surgical or endovascular interventions, besides caesarean section, were performed in 46% of the obstetric group. Perinatal death occurred in 17.2% and of the surviving infants, 63.2% were born preterm and 45.1% required Neonatal Intensive Care Unit admission.

Conclusions

Cardiovascular disease is the most important indication for admission and oncologic disease is associated with highest mortality in women of reproductive age. Obstetric patients constitute a small percentage of all ICU admissions in a tertiary ICU center. They have lower mortality rates than non-obstetric young female patients, despite a more severe initial presentation. Nevertheless lasting maternal morbidity and perinatal mortality and morbidity is frequent.

Racial/Ethnic Disparities in Intensive Care Admissions in a Pregnant and Postpartum Population, Hawai'i, 2012-2017

OBJECTIVE

Maternal morbidity and mortality is a global concern despite advances in medical care and technology and improved economic resources of nations worldwide. The primary objective of our study was to describe racial/ethnic disparities in severe maternal morbidity by using admission to an intensive care unit (ICU) as a marker. The secondary objective was to evaluate associations between patient characteristics, including obstetric outcomes, and severe maternal morbidity.

METHODS

This retrospective cohort study used a large inpatient database to identify pregnancy and postpartum hospitalizations in Hawai'i from January 2012 through September 2017. We evaluated associations between sociodemographic and clinical characteristics and race/ethnicity by using χ² tests. We used multivariable logistic regression to assess associations between race/ethnicity and ICU admission. We used a post hoc analysis to assess associations between ICU admission and obstetric outcomes by race/ethnicity.

RESULTS

After adjustment, we found a significantly higher ICU admission rate among Asian (adjusted odds ratio [aOR] = 1.30; 95% CI, 1.04-1.62; P = .02), Filipino (aOR = 1.45; 95% CI, 1.17-1.79; P < .001), and Native Hawaiian/Other Pacific Islander (aOR = 1.39; 95% CI, 1.15-1.68; P < .001) women compared with non-Hispanic White women. Multiple clinical characteristics and outcomes were associated with ICU admission, such as preexisting chronic conditions and pregnancy-induced hypertensive disorders.

CONCLUSION

We found that severe maternal morbidity represented by ICU admission is higher among Asian, Filipino, and Native Hawaiian/Other Pacific Islander women than among non-Hispanic White women in Hawai'i. Our findings reemphasize the need for health care providers to be vigilant in caring for members of racial/ethnic minority groups and managing their comorbidities.

High mortality rate of obstetric critically ill women in Rwanda and its predictability

BACKGROUND

Reasons for admission to intensive care units (ICUs) for obstetric patients vary from one setting to another. Outcomes from ICU and prediction models are not well explored in Rwanda owing to lack of appropriate scores. This study aimed to assess reasons for admission and accuracy of prediction models for mortality of obstetric patients admitted to ICUs of two public tertiary hospitals in Rwanda.

METHODS

We prospectively collected data from all obstetric patients admitted to the ICUs of the two public tertiary hospitals in Rwanda from March 2017 to February 2018 to identify reasons for admission, demographic and clinical characteristics, outcome including death and its predictability by both the Modified Early Obstetric Warning Score (MEOWS) and quick Sequential Organ Failure Assessment (qSOFA). We analysed the accuracy of mortality prediction models by MEOWS or qSOFA by using logistic regression adjusting for factors associated with mortality. Area under the Receiver Operating characteristic (AUROC) curves is used to show the predicting capacity for each individual tool.

RESULTS

Obstetric patients (n = 94) represented 12.8 % of all 747 ICU admissions which is 1.8 % of all 4.999 admitted women for pregnancy or labor. Sepsis (n = 30; 31.9 %) and obstetric haemorrhage (n = 24; 25.5 %) were the two commonest reasons for ICU admission. Overall ICU mortality for obstetric patients was 54.3 % (n = 51) with average length of stay of 6.6 ± 7.525 days. MEOWS score was an independent predictor of mortality (adjusted (a)OR 1.25; 95 % CI 1.07-1.46) and so was qSOFA score (aOR 2.81; 95 % CI 1.25-6.30) with an adjusted AUROC of 0.773 (95 % CI 0.67-0.88) and 0.764 (95 % CI 0.65-0.87), indicating fair accuracy for ICU mortality prediction in these settings of both MEOWS and qSOFA scores.

CONCLUSIONS

Sepsis and obstetric haemorrhage were the commonest reasons for obstetric admissions to ICU in Rwanda. MEOWS and qSOFA scores could accurately predict ICU mortality of obstetric patients in resource-limited settings, but larger studies are needed before a recommendation for their use in routine practice in similar settings.

Maternal Risk Modeling in Critical Care-Development of a Multivariable Risk Prediction Model for Death and Prolonged Intensive Care

OBJECTIVES

We aimed to develop and validate an accurate risk prediction model for both mortality and a combined outcome of mortality and morbidity for maternal admissions to critical care.

DESIGN

We used data from a high-quality prospectively collected national database, supported with literature review and expert opinion. We tested univariable associations between each risk factor and outcome. We then developed two separate multivariable logistic regression models for the outcomes of acute hospital mortality and death or prolonged ICU length of stay. We validated two parsimonious risk prediction models specific for a maternal population.

SETTING

The Intensive Care National Audit and Research Centre Case Mix Programme is the national clinical audit for adult critical care in England, Wales, and Northern Ireland.

PATIENTS

All female admissions to adult general critical care units, for the period January 1, 2007-December 31, 2016, 16-50 years old, and admitted either while pregnant or within 42 days of delivery-a cohort of 15,480 women.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We aimed to develop and validate an accurate risk prediction model for both mortality and a combined outcome of mortality and morbidity for maternal admissions to critical care. For the primary outcome of acute hospital mortality, our parsimonious risk model consisting of eight variables had an area under the receiver operating characteristic of 0.96 (95% CI, 0.91-1.00); these variables are commonly available for all maternal admissions. For the secondary composite outcome of death or ICU length of stay greater than 48 hours, the risk model consisting of 17 variables had an area under the receiver operating characteristic of 0.80 (95% CI, 0.78-0.83).

CONCLUSIONS

We developed risk prediction models specific to the maternal critical care population. The models compare favorably against general adult ICU risk prediction models in current use within this population.

Maternal Intensive Care Unit Admission as an Indicator of Severe Acute Maternal Morbidity: A Population-Based Study

BACKGROUND

Severe acute maternal morbidity (SAMM) accounts for any life-threatening complication during pregnancy or after delivery. Measuring and monitoring SAMM seem critical to assessing the quality of maternal health care. The objectives were to explore the validity of intensive care unit (ICU) admission as an indicator of SAMM by characterizing the profile of women admitted to an ICU and of their ICU stay, according to the association with other SAMM criterion.

METHODS

We performed a secondary analysis of the 2540 women with SAMM included in the epidemiology of severe acute maternal morbidity (EPIMOMS) multiregional prospective population-based study (2012-2013, n = 182,309 deliveries). The EPIMOMS definition of SAMM, based on national experts' consensus, is a combination of diagnosis, organ dysfunctions, and intervention criteria, including ICU admission. Among women with SAMM, we identified characteristics associated with maternal ICU admission with or with no other SAMM criterion compared with ICU admission, by using multivariable multinomial logistic regression models.

RESULTS

Overall, 511 women were admitted to an ICU during or up to 42 days after pregnancy, for a population-based rate of 2.8 of 1000 deliveries (511/182,309; 95% confidence interval [CI], 2.6-3.1); 15.5% of them (79/511; 95% CI, 12.4-18.9) had no other SAMM criterion compared with ICU admission. Among women with SAMM, the odds of ICU admission with no other morbidity criterion were increased in women with preexisting medical conditions (adjusted odds ratio (aOR), 2.13; 95% CI, 1.17-3.86) and cesarean before labor (aOR, 3.12; 95% CI, 1.47-6.64). Women admitted to ICU with no other SAMM criterion had more often decompensation of a preexisting condition, no interventions for organ support, and a shorter length of stay than women admitted with other SAMM criteria.

CONCLUSIONS

Among women with SAMM, 1 in 5 is admitted to an ICU; 15.5% of those admitted in ICU have no other SAMM criterion and a less acute condition. These results challenge the use of ICU admission as a criterion of SAMM.

Role of Critical Care Units in the management of obstetric patients (Review)

Pregnancy is considered a natural process for the majority of women. However, a limited proportion of pregnancies and deliveries can present with a broad variety of complications that may require admission to a Critical Care Unit (CCU). In the present review, the indications of admission of obstetrical and postpartum patients to CCUs were critically evaluated with a particular focus on the management of their complications. The management of critically ill obstetric patients remains challenging due to the physiological changes that occur during pregnancy, pregnancy-related diseases and the need to carefully consider the well-being of the fetus before any intervention can be recommended/performed. Indications for admission to CCUs include both obstetric and non-obstetric conditions that may require continuous monitoring and further interventions. Hypertensive disorders of pregnancy and mass hemorrhage are amongst the most common causes of admission to CCUs in pregnant and postpartum women. The establishment of a diagnostic and care algorithm based on the contribution of a multidisciplinary team is of critical importance to aid in the determination of which patients will require intensive care, and to assist in deciding what type of critical care each critically ill patients receives.