Why do obstetric patients go to the ICU? A 3-year-study

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.

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

Introduction:

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

Methods:

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

Results:

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

Conclusions:

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

Profile of Obstetric Patients in Intensive Care Unit: A Retrospective Study from a Tertiary Care Center in North India

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.

Epidemiology, Outcomes, and Risk Factors for Mortality in Critically Ill Women Admitted to an Obstetric High-Dependency Unit in Sierra Leone

A better understanding of the context-specific epidemiology, outcomes, and risk factors for death of critically ill parturients in resource-poor hospitals is needed to tackle the still alarming in-hospital maternal mortality in African countries. From October 2017 to October 2018, we performed a 1-year retrospective cohort study in a referral maternity hospital in Freetown, Sierra Leone. The primary endpoint was the association between risk factors and high-dependency unit (HDU) mortality. Five hundred twenty-three patients (median age 25 years, interquartile range [IQR]: 21-30 years) were admitted to the HDU for a median of 2 (IQR: 1-3) days. Among them, 65% were referred with a red obstetric early warning score (OEWS) code, representing 1.17 cases per HDU bed per week; 11% of patients died in HDU, mostly in the first 24 hours from admission. The factors independently associated with HDU mortality were ward rather than postoperative referrals (odds ratio [OR]: 3.21; 95% CI: 1.48-7.01; P = 0.003); admissions with red (high impairment of patients' vital signs) versus yellow (impairment of vital signs) or green (little or no impairment of patients' vital signs) OEWS (OR: 3.66; 95% CI: 1.15-16.96; P = 0.04); responsiveness to pain or unresponsiveness on the alert, voice, pain unresponsive scale (OR: 5.25; 95% CI: 2.64-10.94; P ≤ 0.0001); and use of vasopressors (OR: 3.24; 95% CI: 1.32-7.66; P = 0.008). Critically ill parturients were predominantly referred with a red OEWS code and usually required intermediate care for 48 hours. Despite the provided interventions, death in the HDU was frequent, affecting one of 10 critically ill parturients. Medical admission, a red OEWS code, and a poor neurological and hemodynamic status were independently associated with mortality, whereas adequate oxygenation was associated with survival.

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

Introduction

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

Materials and methods

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

Results

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

Conclusion

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

How to cite this article

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

Critical Care in Obstetrics: Where are We

Maternal mortality is disastrous news for the society, family, newborn, and the obstetrician. Yet, we all who are care providers to these apparently healthy women carrying another life within them are dumbfounded by the clinical conditions arising due to the pregnancy or the effects of the pregnancy, that it becomes difficult to provide an ideal care to them. The rapid uprising of a condition and the worsening of commonly occurring benign conditions-preeclampsia, hemorrhage, etc., necessitates that all obstetricians are well versed with the physiological changes and should be able to not only provide the best of obstetric care to the mother and the newborn but also perform or assist in performance of life-saving procedures.

Outcomes of Antepartum and Postpartum Obstetric Admissions to the Intensive Care Unit of A Tertiary University Hospital: An 8-Year Review

Objective

Although their rates are decreasing, pregnancy-related mortality and morbidity are problems worldwide. In this study, we aimed to review the characteristics, diagnoses, required interventions and outcomes of obstetric patients admitted between 2006 and 2014 to the Intensive Care Unit (ICU) of a tertiary university hospital to provide an indicator for improving the management of critically ill obstetric patients.

Methods

A retrospective study of hospital records of obstetric admissions to the ICU was conducted.

Results

The pregnancy-related ICU admission rate was 0.21% among all deliveries during the study period. Nine antepartum (mean gestational age: 23 weeks) and 48 postpartum (mean gestational age: 34 weeks) obstetric ICU admissions were included. Most obstetric patients admitted antepartum were primiparous (88.8%), whereas those admitted postpartum were multiparous (64.6%). The mean ICU stay was 7 days among the patients admitted antepartum and 6 days among those admitted postpartum. Common medical reasons for ICU admission were respiratory failure and HELLP syndrome in both groups; DIC and eclampsia were also medical reasons causing ICU admission among the postpartum patients. Mechanical ventilation and blood derivative transfusion were the most common interventions required during the ICU stay of the obstetric patients. Maternal death was unique to the patients admitted postpartum (6 patients, 12.5%).

Conclusion

We reviewed obstetric admissions to our institution over an 8-year period. We believe that a nationwide study in Turkey that provides an indicator of the frequency, reasons of ICU admission and outcome of obstetric patients is required to improve the quality of intensive care.

Critically Ill Obstetric Patients in a General Critical Care Unit: A 5 Years' Retrospective Study in a Public Teaching Hospital of Eastern India

Background:

Critical care services are essential for the subset of obstetric patients suffering from severe maternal morbidity. Studies on obstetric critical care are important for benchmarking the issues which need to be addressed while managing critically ill obstetric patients. Although there are several published studies on obstetric critical care from India and abroad, studies from Eastern India are limited. The present study was conducted to fill in this lacuna and to audit the obstetric critical care admissions over a 5 years’ period.

Settings and Design:

Retrospective cohort study conducted in the general critical care unit (CCU) of a government teaching hospital.

Materials and Methods:

The records of all obstetric patients managed in the CCU over a span of 5 years (January 2011-December 2015) were analyzed.

Results:

During the study, 205 obstetric patients were admitted with a CCU admission rate of 2.1 per 1000 deliveries. Obstetric hemorrhage (34.64%) was the most common primary diagnosis among them followed by pregnancy-induced hypertension (26.83%). Severe hemorrhage leading to organ failure (40.48%) was the main direct indication of admission. Invasive ventilation was needed in 75.61% patients, and overall obstetric mortality rate was 33.66%. The median duration (in days) of invasive ventilation was 2 (interquartile range [IQR] 1-7), and the median length of CCU stay (in days) was 5 (IQR 3-9).

Conclusions:

Adequate number of critical care beds, a dedicated obstetric high dependency unit, and effective coordination between critical care and maternity services may prove helpful in high volume obstetric centers.