Obstetric admissions to the intensive care unit

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.

Obstetric Admissions in ICU in a Tertiary Care Center: A 5-Years Retrospective Study

Background and Aim

Obstetric patients admitted to intensive care unit (ICU) represent a challenge to physicians. The purpose of this study is to evaluate the incidence, characteristics, and mortality of pregnant and postpartum patients requiring ICU admission.

Materials and Methods

A retrospective cohort study was performed between January 2008 and December 2013 at the University Hospital Federico II of Naples including pregnant and puerperal women until the 42nd day of postpartum and admitted to ICU.

Results

Patients admitted with an obstetric diagnosis had a higher incidence of at least one previous cesarean section, were treated more with hysterectomy, had an increasing incidence of hemodynamic instability, had more postpartum admission, had a higher TISS-28 score, and required more endotracheal intubation than patients admitted with non-obstetrics diagnosis.

Conclusion

A shared approach including a close collaboration between ICU and obstetric ward may be useful to reduce ICU admission and to improve maternal and foetal outcomes.

How to cite this article

Vargas M, Marra A, Buonanno P, Iacovazzo C, Schiavone V, Servillo G. Obstetric Admissions in ICU in a Tertiary Care Center. A 5-years Retrospective Study. Indian J Crit Care Med 2019;23(5):213-219.

Outcomes of patients admitted to the intensive care unit for complications of hypertensive disorders of pregnancy at a South African tertiary hospital - a 4-year retrospective review

Background

Hypertensive disorders of pregnancy (HDP) are a major cause of maternal mortality and adverse outcomes. A previous study in the intensive care unit (ICU) at King Edward VIII Hospital, Durban, South Africa, in 2000 found 10.5% mortality among eclampsia patients.

Objectives

To describe the mortality and adverse neurological outcomes associated with HDP in a tertiary ICU, compare these with results from 2000 and describe factors associated therewith.

Methods

The data of 85 patients admitted with HDP to ICU at King Edward VIII Hospital from 2010 to 2013 were retrospectively reviewed. Mortality and adverse neurological outcome (Glasgow Coma Scale (GCS) ≤14 on discharge from ICU) were assessed. Two sets of analyses were conducted. The first compared those alive on discharge from ICU with those who died in ICU. The second compared good neurological outcome with poor outcome (adverse neurological outcome, or death).

Results

The mortality was 11.6%, and overall, 9% had adverse neurological outcomes. There was no significant difference in mortality between patients with eclampsia in 2010 - 2013 (11.0%) and those in 2000 (10.5%) (p=0.9). Factors associated with mortality were: intra- or postpartum onset of seizures; twins; failure to perform operative delivery when indicated; lowest GCS score <10; failure to use magnesium sulphate when indicated; respiratory failure; and lower respiratory tract infections. Factors associated with poor outcomes (adverse neurological outcome, or death) were: parity (better outcomes in primiparous patients); time of antenatal onset of hypertension (worse if earlier onset); HIV infection; failure to perform operative delivery when indicated; lowest GCS score <10; failure to use magnesium sulphate when indicated; use of anticonvulsants other than magnesium sulphate or benzodiazepines in eclampsia.

Conclusion

The lack of improvement in ICU eclampsia mortality demonstrates a need to develop and implement a protocol for HDP management.

Contributions of the study

The study provides a comparison of present mortality among eclamptic patients with hyperensive disorders of pregnancy (HDP) with the mortality of eclamptic patients described in an article from the year 2000. It further looks at adverse maternal outcomes, specifically adverse neurological outcomes.In addition, it analyses other factors that may affect outcomes in HDP patients. This information is useful in making recommendations in an attempt to improve the outcomes.

Risk prediction models for maternal mortality: A systematic review and meta-analysis

PURPOSE

Pregnancy-related critical illness leads to death for 3-14% of affected women. Although identifying patients at risk could facilitate preventive strategies, guide therapy, and help in clinical research, no prior systematic review of this literature exploring the validity of risk prediction models for maternal mortality exists. Therefore, we have systematically reviewed and meta-analyzed risk prediction models for maternal mortality.

METHODS

Search strategy: MEDLINE, EMBASE and Scopus, from inception to May 2017. Selection criteria: Trials or observational studies evaluating risk prediction models for maternal mortality. Data collection and analysis: Two reviewers independently assessed studies for eligibility and methodological quality, and extracted data on prediction performance.

RESULTS

Thirty-eight studies that evaluated 12 different mortality prediction models were included. Mortality varied across the studies, with an average rate 10.4%, ranging from 0 to 41.7%. The Collaborative Integrated Pregnancy High-dependency Estimate of Risk (CIPHER) model and the Maternal Severity Index had the best performance, were developed and validated from studies of obstetric population with a low risk of bias. The CIPHER applies to critically ill obstetric patients (discrimination: area under the receiver operating characteristic curve (AUC) 0.823 (0.811-0.835), calibration: graphic plot [intercept-0.09, slope 0.92]). The Maternal Severity Index applies to hospitalized obstetric patients (discrimination: AUC 0.826 [0.802-0.851], calibration: standardized mortality ratio 1.02 [0.86-1.20]).

CONCLUSIONS

Despite the high heterogeneity of the study populations and the limited number of studies validating the finally eligible prediction models, the CIPHER and the Maternal Severity Index are recommended for use among critically ill and hospitalized pregnant and postpartum women for risk adjustment in clinical research and quality improvement studies. Neither index has sufficient discrimination to be applicable for clinical decision making at the individual patient level.

Indications and characteristics of obstetric patients admitted to the intensive care unit: a 22-year review in a tertiary care center

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.

Risk of retained placenta in women previously delivered by caesarean section: a population-based cohort study

OBJECTIVE

To evaluate whether women with a caesarean section at their first delivery have an increased risk of retained placenta at their second delivery.

DESIGN

Population-based cohort study.

SETTING

Sweden.

POPULATION

All women with their first and second singleton deliveries in Sweden during the years 1994-2006 (n = 258,608). Women with caesarean section or placental abruption in their second pregnancy were not included in the study population.

METHODS

The risk of retained placenta at second delivery was estimated for women with a first delivery by caesarean section (n = 19,458), using women with a first vaginal delivery as reference (n = 239,150). Risks were calculated as odds ratios by unconditional logistic regression analysis with 95% confidence intervals (95%) after adjustments for maternal, delivery, and infant characteristics.

MAIN OUTCOME MEASURES

Retained placenta with normal (≤1000 ml) and heavy (>1000 ml) bleeding.

RESULTS

The overall rate of retained placenta was 2.07%. In women with a previous caesarean section and in women with previous vaginal delivery, the corresponding rates were 3.44% and 1.96%, respectively. Compared with women with a previous vaginal delivery, women with a previous caesarean section had an increased risk of retained placenta (adjusted OR 1.45; 95% CI 1.32-1.59), and the association was more pronounced for retained placenta with heavy bleeding (adjusted OR 1.61; 95% CI 1.44-1.79).

CONCLUSIONS

Our report shows an increased risk for retained placenta in women previously delivered by caesarean section, a finding that should be considered in discussions of mode of delivery.

Evaluation of obstetric admissions to intensive care unit of a tertiary referral center in coastal India

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.

Clinical Profile of Obstetric Patients Admitted to the Medical-Surgical Intensive Care Unit (MSICU) of an Inner-City Hospital in New York

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.

Delivering obstetrical critical care in developing nations

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

Maternal outcomes in critically ill obstetrics patients: A unique challenge

Background:

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

Materials and Methods:

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

Study Design and Setting:

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

Results and Conclusion:

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

Sequential organ failure assessment score for evaluating organ failure and outcome of severe maternal morbidity in obstetric intensive care

Objective. To evaluate the performance of Sequential Organ Failure Assessment (SOFA) score in cases of severe maternal morbidity (SMM). Design. Retrospective study of diagnostic validation. Setting. An obstetric intensive care unit (ICU) in Brazil. Population. 673 women with SMM. Main Outcome Measures. mortality and SOFA score. Methods. Organ failure was evaluated according to maximum score for each one of its six components. The total maximum SOFA score was calculated using the poorest result of each component, reflecting the maximum degree of alteration in systemic organ function. Results. highest total maximum SOFA score was associated with mortality, 12.06 ± 5.47 for women who died and 1.87 ± 2.56 for survivors. There was also a significant correlation between the number of failing organs and maternal mortality, ranging from 0.2% (no failure) to 85.7% (≥3 organs). Analysis of the area under the receiver operating characteristic (ROC) curve (AUC) confirmed the excellent performance of total maximum SOFA score for cases of SMM (AUC = 0.958). Conclusions. Total maximum SOFA score proved to be an effective tool for evaluating severity and estimating prognosis in cases of SMM. Maximum SOFA score may be used to conceptually define and stratify the degree of severity in cases of SMM.

Clinical characteristics and outcomes of critically ill obstetric patients: a ten-year review

BACKGROUND AND OBJECTIVES

Pregnancy and delivery can involve complications that necessitate admission to critical care facilities. The objective of our study was to assess the incidence, indications, and outcomes of obstetric patients requiring admission to an intensive care unit (ICU) in a tertiary care hospital, in Saudi Arabia.

DESIGN AND SETTING

Retrospective cohort study of consecutive obstetric admissions to the ICU at the King Abdulaziz Medical City over a 10-year period.

PATIENTS AND METHODS

We collected baseline demographic data and acute physiology and chronic health evaluation II (APACHE II) scores. ICU mortality was the primary outcome.

RESULTS

Over 10 years, 75 obstetric patients were admitted to the ICU, and 59 of these patients (78.6%) were admitted during the antepartum period. The main obstetric indication for ICU admission was pregnancy-induced hypertension (21 patients, 28%) and the leading non-obstetric indication was sepsis (12 patients, 16%). The APACHE II score was 19.59 (15.05). The predicted mortality rate based on the APACHE II score was 21.97%; however, there were only six maternal deaths (8%) among the obstetric patients admitted to the ICU.

CONCLUSION

The overall mortality was low. A team approach facilitated the application of optimal care to these patients. Obstetric patients had better outcomes than those predicted by the APACHE II scores. Appropriate antenatal care is important for preventing obstetric complications.

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

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

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Severe 2009 H1N1 influenza in pregnant and postpartum women in California

BACKGROUND

Like previous epidemic and pandemic diseases, 2009 pandemic influenza A (H1N1) may pose an increased risk of severe illness in pregnant women.

METHODS

Statewide surveillance for patients who were hospitalized with or died from 2009 H1N1 influenza was initiated by the California Department of Public Health. We reviewed demographic and clinical data reported from April 23 through August 11, 2009, for all H1N1-infected, reproductive-age women who were hospitalized or died--nonpregnant women, pregnant women, and postpartum women (those who had delivered < or = 2 weeks previously).

RESULTS

Data were reported for 94 pregnant women, 8 postpartum women, and 137 nonpregnant women of reproductive age who were hospitalized with 2009 H1N1 influenza. Rapid antigen tests were falsely negative in 38% of the patients tested (58 of 153). Most pregnant patients (89 of 94 [95%]) were in the second or third trimester, and approximately one third (32 of 93 [34%]) had established risk factors for complications from influenza other than pregnancy. As compared with early antiviral treatment (administered < or = 2 days after symptom onset) in pregnant women, later treatment was associated with admission to an intensive care unit (ICU) or death (relative risk, 4.3). In all, 18 pregnant women and 4 postpartum women (total, 22 of 102 [22%]) required intensive care, and 8 (8%) died. Six deliveries occurred in the ICU, including four emergency cesarean deliveries. The 2009 H1N1 influenza-specific maternal mortality ratio (the number of maternal deaths per 100,000 live births) was 4.3.

CONCLUSIONS

2009 H1N1 influenza can cause severe illness and death in pregnant and postpartum women; regardless of the results of rapid antigen testing, prompt evaluation and antiviral treatment of influenza-like illness should be considered in such women. The high cause-specific maternal mortality rate suggests that 2009 H1N1 influenza may increase the 2009 maternal mortality ratio in the United States.

Obstetric intensive care unit admission: a 2-year nationwide population-based cohort study

PURPOSE

As part of a larger nationwide enquiry into severe maternal morbidity, our aim was to assess the incidence and possible risk factors of obstetric intensive care unit (ICU) admission in the Netherlands.

METHODS

In a 2-year nationwide prospective population-based cohort study, all ICU admissions during pregnancy, delivery and puerperium (up to 42 days postpartum) were prospectively collected. Incidence, case fatality rate and possible risk factors were assessed, with special attention to the ethnic background of women.

RESULTS

All 98 Dutch maternity units participated in the study. There were 847 obstetric ICU admissions in 358,874 deliveries, the incidence being 2.4 per 1,000 deliveries. Twenty-nine maternal deaths occurred, resulting in a case fatality rate of 1 in 29 (3.5%). Incidence of ICU admission varied largely across the country. Thirty-three percent of all cases of severe maternal morbidity were admitted to an ICU. Most frequent reasons for ICU admission were major obstetric haemorrhage (48.6%), hypertensive disorders of pregnancy (29.3%) and sepsis (8.1%). Assisted ventilation was needed in 34.8%, inotropic support in 8.8%. In univariable analysis, non-Western immigrant women had a 1.4-fold (95% CI 1.2-1.7) increased risk of ICU admission as compared to Western women. Initial antenatal care by an obstetrician was associated with a higher risk and home delivery with a lower risk of ICU admission.

CONCLUSIONS

Population-based incidence of obstetric ICU admission in the Netherlands was 2.4 per 1,000 deliveries. Obstetric ICU admission accounts for only one-third of all cases of severe maternal morbidity in the Netherlands.

Effects of onset of labor and mode of delivery on severe postpartum hemorrhage

OBJECTIVE

Our purpose was to study the impact of labor onset and delivery mode on the risk of severe postpartum hemorrhage.

STUDY DESIGN

This was a population-based study of 307,415 mothers who were registered in the Medical Birth Registry of Norway from 1999-2004.

RESULTS

Severe postpartum hemorrhage occurred in 1.1% of all mothers and in 2.1% of those mothers with previous cesarean section delivery (CS). Compared with spontaneous labor, hemorrhage risk was higher for induction (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.56-1.88) and prelabor CS (OR, 2.05; 95% CI, 1.84-2.29). The risk was 55% higher for emergency CS and half that for vaginal deliveries (OR, 0.48; 95% CI, 0.43-0.53), compared with prelabor CS. The highest risk was for emergency CS after induction in mothers with previous CS (OR, 6.57; 95% CI, 4.25-10.13), compared with spontaneous vaginal delivery in mothers with no previous CS.

CONCLUSION

Induction and prelabor CS should be practiced with caution because of the increased risk of severe postpartum hemorrhage.

Audit of severe acute morbidity in hypertensive pregnancies in a developing country

The aim of this study was to establish a population-based incidence of severe acute maternal morbidity (SAMM) in hypertensive pregnancies and to assess if substandard care was unique to cases of SAMM and mortality or whether it was apparent in uncomplicated pregnancies as well. The population-based incidence of hypertension was 12%. Using defined criteria for SAMM, the incidence of SAMM was 3/1000 deliveries. The MMR was 42/100000 deliveries, i.e. SAMM is seven times greater than the mortality. Substandard care was similar in cases of SAMM and mortality and uncomplicated hypertensive patients. Audit of SAMM is informative, can be conducted more frequently, and in small sample population groups. It also allows interviews of patients, hence problems of inefficient documentation is obviated.

Management of the unconscious pregnant patient

The management of the unconscious pregnant patient encompasses many aspects of obstetrics and critical care. It is not uncommon to have to manage such a patient, therefore one needs to be well prepared. There is a spectrum of altered consciousness, brain death being the most extreme. The causes of unconsciousness can be general or pregnancy specific. It is important to consider the physiological changes in pregnancy when managing these patients. The immediate resuscitative measures are mostly the same as for the nonpregnant with a few modifications. It is important to remember that there are two patients involved and this can complicate management issues. A multidisciplinary approach would be prudent. The intermediate and long-term management should also involve the family. The issues of perimortem and somatic support for foetal maturity are also discussed.

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

CONTEXT

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

METHODS

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

RESULTS

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

CONCLUSION

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

Epidemiology of obstetric critical care

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

Appropriate criteria for identification of near-miss maternal morbidity in tertiary care facilities: a cross sectional study

Background

The study of severe maternal morbidity survivors (near miss) may be an alternative or a complement to the study of maternal death events as a health care indicator. However, there is still controversy regarding the criteria for identification of near-miss maternal morbidity. This study aimed to characterize the near miss maternal morbidity according to different sets of criteria.

Methods

A descriptive study in a tertiary center including 2,929 women who delivered there between July 2003 and June 2004. Possible cases of near miss were daily screened by checking different sets of criteria proposed elsewhere. The main outcome measures were: rate of near miss and its primary determinant factors, criteria for its identification, total hospital stay, ICU stay, and number and kind of special procedures performed.

Results

There were two maternal deaths and 124 cases of near miss were identified, with 102 of them admitted to the ICU (80.9%). Among the 126 special procedures performed, the most frequent were central venous access, echocardiography and invasive mechanical ventilation. The mean hospital stay was 10.3 (± 13.24) days. Hospital stay and the number of special procedures performed were significantly higher when the organ dysfunction based criteria were applied.

Conclusion

The adoption of a two level screening strategy may lead to the development of a consistent severe maternal morbidity surveillance system but further research is needed before worldwide near miss criteria can be assumed.

Temporizing treatment for the respiratory-compromised gravida: an observational study of maternal and neonatal outcome

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.

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

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

Obstetric critical care: a blueprint for improved outcomes

INTRODUCTION

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

PURPOSE

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

RESULTS

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

CONCLUSION

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

Obstetric intensive care admissions: A 12-year review in a tertiary care centre

OBJECTIVE

To review all pregnant women who required admission to an Intensive Care Unit (ICU) during pregnancy, childbirth or puerperium.

STUDY DESIGN

Retrospective follow-up study in a tertiary care centre in The Netherlands. The files of all obstetric ICU admissions over the period 1990-2001 were reviewed.

RESULTS

Over these 12 years, 142 women required ICU admission (0.76% of all deliveries, 0.70% of all adult ICU admissions). The most common reasons for ICU admission were (pre)eclampsia (62.0%) and obstetric haemorrhage (18.3%). Twenty-seven out of 142 women (19.0%) were of non-caucasian origin. The most common therapeutic interventions were transfusion of erythrocytes (66.2%), caesarean section (50.7%) and artificial ventilation (44.4%). We observed seven maternal deaths (4.9%).

CONCLUSION

We need better information about high-risk obstetric patients in order to prevent severe maternal morbidity and to improve maternal care. The high number of non-caucasian women requiring ICU admission indicates the need for a study into the role of ethnicity. We have initiated a nationwide confidential enquiry into the causes of severe maternal morbidity.

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

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

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Utility of Acute Physiology, Age, and Chronic Health Evaluation (APACHE III) score in maternal admissions to the intensive care unit

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.

Sepsis during pregnancy

OBJECTIVES

To provide a current review of the literature regarding the assessment and management of sepsis during pregnancy.

DESIGN

A comprehensive review of current English-language literature search was performed with Ovid MEDLINE using the Medical Subject Headings pregnancy and sepsis, with Medical Subject Headings or keywords seeking randomized controlled trials and clinical reports, and by reviewing the bibliographies of clinical practice guidelines.

RESULTS

Sepsis-related maternal morbidity and mortality is a significant and persistent problem in the modern critical care obstetric unit. The management of sepsis during pregnancy is challenging. The obstetric intensivist must simultaneously discern the effect of maternal physiologic changes on fetal vulnerability and the effect of the fetus on maternal status throughout the various phases of pregnancy. Little direct evidence exists to validate the extrapolation of some sepsis treatment modalities from other nonpregnant patient populations. Nevertheless, early detection, accurate diagnosis, and aggressive appropriate treatment strategies may significantly improve outcome. Approaches like the Surviving Sepsis Campaign guidelines are unproven but seem reasonable and practical.

CONCLUSIONS

Sepsis during pregnancy is uncommon yet potentially fatal. Diagnostic and therapeutic guidelines should predominantly pattern those currently utilized for nonpregnant patients.

Cardiopulmonary complications of pregnancy

OBJECTIVES

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

DESIGN

A review of the current literature was performed.

RESULTS

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

CONCLUSIONS

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

Maternity wards or emergency obstetric rooms? Incidence of near-miss events in African hospitals

BACKGROUND

This study examines near-miss obstetric events in African hospitals as to the frequency, nature, and ratio of near miss to death and considers whether these could become useful indicators for monitoring the performance of obstetric services in Africa.

METHODS

Prospective or retrospective reviews of medical records were conducted in nine referral hospitals in three countries (Benin, Côte d'Ivoire, and Morocco). We calculated the incidence of near-miss obstetric events, near-miss cases, and maternal deaths related to hemorrhage, hypertensive diseases of pregnancy, dystocia, infections, and anemia and analyzed these according to hospital and timing relative to admission.

RESULTS

The incidence of near-miss cases was varied, and in some hospitals extremely large: from 1% to almost a quarter of all deliveries were near misses. Near-miss cases were 15 times more common than deaths (ranging from a ratio of 9:1-108:1). Most of the women with near-miss events (NMEs) (83%) were already in a critical condition on arrival at the hospital (range 54-90%), and two in three were referred from another facility. The most frequent types of NMEs were hemorrhage and hypertensive diseases of pregnancy, but anemia was the leading cause in three first referral level hospitals in Benin and Côte d'Ivoire. Near-miss events due to infections were rare.

CONCLUSIONS

Near-miss events are extremely common in some African hospitals, with a high proportion arriving in critical conditions. Near-miss events must be estimated separately for those already in a critical condition on arrival and those developing after admission; the first as a good indicator of the effectiveness of emergency referrals and the second as a potential tool for monitoring the performance of obstetric services.

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

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

Critical illness and pregnancy: review of a global problem

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

Admission pattern and outcome in critical care obstetric patients

We undertook a six-year retrospective study to determine the pattern of admission and outcome for obstetric patients admitted to the intensive care unit of the University of Nigeria Teaching Hospital, Enugu. The hospital records (case notes and intensive care unit records) were used to extract the necessary data. A total of 816 patients were admitted to the intensive care unit during the period under review. Eighteen (2.2%) were obstetric patients. Nine (50%) were preeclamptic and eclamptic patients. Four patients (22.2%) had obstetric haemorrhage. Five others presented with the following: asthma, postoperative respiratory distress, cervical incompetence, gestational diabetes and hypertension, and caesarean section for terminal carcinoma of the breast. There were six deaths (mortality rate 33.3%). Preeclampsia/eclampsia accounted for four deaths (44% mortality rate amongst preeclamptics/eclamptics), while two deaths accounted for a 50% mortality rate in the obstetric haemorrhage group. This study confirmed similar reports from the advanced nations and Asia that preeclampsia/eclampsia and obstetric haemorrhage are the leading causes of admission to the intensive care unit. The mortality rate in this study is however higher.

Prognostic factors in obstetric patients admitted to an Indian intensive care unit

OBJECTIVES

Obstetric patients form a significant proportion of intensive care unit admissions in countries like India, where maternal mortality is high (440 per 100,000 deliveries). We studied the diseases requiring intensive care and prognostic factors in obstetric patients.

DESIGN

Retrospective chart review. Acute Physiology and Chronic Health Evaluation (APACHE) II data were prospectively collected.

SETTING

Multidisciplinary intensive care unit of a public hospital in Mumbai, India.

PATIENTS

Women admitted during pregnancy or 6 wks post-partum during a 5-yr study period (1997-2001).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Four hundred fifty-three obstetric patients (age 25.5 +/- 4.6 yrs [mean +/- SD], mean gestational age 31 wks) were admitted (548 intensive care unit admissions per 100,000 deliveries), 138 with single organ failure and 152 with multiple organ failure. Ninety-eight women died (mortality rate 21.6%). Mortality was comparable in antepartum (n = 216) and postpartum (n = 247) admissions but increased with increasing number of organs affected. There were 236 fetal deaths (52%), of which 104 occurred before hospital admission. Median APACHE II score was 16 (interquartile range, 10-24), and standardized mortality ratio (observed deaths/predicted deaths) was 0.78. Compared with pregnant patients admitted with obstetric disorders (n = 313), those with medical diseases (n = 140) had significantly lower APACHE II scores (median 14 vs. 17) but higher observed mortality rate (28.6% vs. 18.5%; odds ratio, 1.76; 95% confidence interval, 1.08-2.87) and standardized mortality ratio (1.09 vs. 0.66). On multivariate analysis, increased mortality rate was associated with acute cardiovascular (odds ratio, 5.8), nervous system (odds ratio, 4.73) and respiratory (odds ratio, 12.9) failure, disseminated intravascular coagulation (odds ratio, 2.4), viral hepatitis (odds ratio, 5.8), intracranial hemorrhage (odds ratio, 5.4), absence of prenatal care (odds ratio, 1.94), and >24 hrs interval between onset of acute symptoms and intensive care unit admission (odds ratio, 2.3).

CONCLUSIONS

Multiple organ failure is common in obstetric patients; mortality rate increases with increasing organ failure. APACHE II scores overpredict mortality rate. Standardized mortality ratio is lower in obstetric disorders than in medical disorders. Lack of prenatal care and delay in intensive care unit referral adversely affect outcome and are easily preventable.

Quantifying severe maternal morbidity: a Scottish population study

OBJECTIVE

To quantify the incidence of severe maternal morbidity in Scotland and determine the feasibility of doing so.

DESIGN

Prospective observational study.

SETTING

All 22 consultant led maternity units in Scotland, between 1 October 2001 and 30 September 2002.

POPULATION

Women during pregnancy and the puerperium.

METHODS

Definitions for 13 categories of severe maternal morbidity were developed from published work. Recruitment of maternity units, and training of staff, took place at a national meeting. Each month, every unit reported cases meeting the agreed definitions, the category of incident and date. Data were collated centrally and analysed to determine the frequency of incidents. The number of maternal deaths occurring in Scotland over the same period was obtained from the Confidential Enquiry into Maternal Deaths.

MAIN OUTCOME MEASURES

Number and rate of defined events being reported. A subjective view of the feasibility of collecting national data routinely.

RESULTS

Severe morbidity was reported in 196 women, out of 51,165 deliveries in Scotland (rate 3.8 per 1000 deliveries). Thirty percent of cases fell into more than one defined category. Major obstetric haemorrhage accounted for 50% of events. Only a third of identified patients were admitted to intensive care units. Four relevant maternal deaths occurred.

CONCLUSIONS

Categories of severe maternal morbidity can be defined and may provide a useful measure of the quality of maternity services, particularly in developed countries where maternal mortality is very rare. It appears feasible to set up a national reporting system for maternal morbidity, as well as mortality.