Critically ill parturient women and admission to intensive care: a 5-year review

Perinatal outcome in women with bacterial sepsis: A cross-sectional study from West China

Maternal bacterial sepsis during pregnancy and the postpartum period is a common cause of maternal mortality and fetal morbidity and mortality. This study was performed to analyze perinatal prognosis and related factors of maternal bacterial sepsis in west China.We conducted a cross-sectional study of pregnant women with bacterial sepsis who were admitted into a tertiary care center in western China between 2011and 2015. Data from these cases were collected and analyzed.Eighty six women were identified with bacterial sepsis in our hospital, and the incidence of maternal bacterial sepsis was 1.7 per 1000 maternities, the incidence of septic shock was 1.8 per 10,000 maternities, and 1 maternal death occurred. Among the 86 pregnant women with bacterial sepsis, genital tract infection was the most common source of infection (41/86, 47.7%). The most common bacteria in the Gram-positive bacteria group was Listeria monocytogenes and in the Gram-negative bacteria group was Escherichia coli. The premature delivery rate (65.7%) was substantially higher in the Gram-negative bacteria group (P = .011), and the miscarriage rate (31.3%) was higher in the Gram-positive bacteria group (P = .042). The fetal/neonatal mortality rate was 20% (21/105) and higher in the Gram-positive bacteria group (P = .008), and the infant mortality rate in 1 year was 7.1% (6/84).Bacterial sepsis remains an alarming cause of both maternal and fetal morbidity and mortality, and infant mortality. Key treatment involves a multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women with sepsis and early initiation of appropriate antibiotics according to the type of bacterial infection. The effect of maternal sepsis on long-term fetal outcome should be investigated.

Practice Bulletin No. 170: Critical Care in Pregnancy

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

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.

Is intensive care the only answer for high risk pregnancies in developing nations?

BACKGROUND

Management of high risk obstetric patients.

AIM

The present study was conducted to evaluate the primary causes of the admission of obstetric patients to Intensive Care Unit (ICU), the presence of co-morbid diseases, outcome of such patients, their survival rate as well as the factors which contribute to the maternal mortality.

SETTINGS AND DESIGN

A retrospective study was conducted in the Department of Obstetrics and Gynaecology and Anaesthesiology/ICU of our Institute.

MATERIALS AND METHODS

Sixty-one obstetric patients, who were admitted to ICU between 20 December 2006 and 31 January 2010, were evaluated for various factors responsible for their admission as well as their outcome.

STATISTICAL ANALYSIS

At the end of study, the data were arranged systematically and subjected to statistical analysis using nonparametric tests and P value <0.05 was considered significant.

RESULTS

Majority of the 61 patients admitted in ICU were referred from the peripheral health centers, smaller nursing homes/hospitals and some even without proper primary care and mainly comprising uneducated and rural population. Hemorrhage, pregnancy induced hypertension, cardiac diseases, respiratory insufficiency and sepsis were the main causes for admission. A total of 18 patients among 61 died during their ICU stay in the hospital.

CONCLUSIONS

In the developing countries, high risk pregnancy should be managed at peripheral centers with proper facilities, antenatal visits and timely referral. The intensive care help should be reserved for very high risk pregnancies with co-morbid diseases.

Indications and outcome for obstetric patients' admission to intensive care unit: a 7-year review

The objective of this retrospective study was to investigate the indications, interventions and clinical outcome of pregnant and newly delivered women admitted to the multidisciplinary intensive care unit at the King Abdullah University Hospital in Jordan over a 7-year period from January 2002 to December 2008. The collected data included demographic characteristics of the patients, mode of delivery, pre-existing medical conditions, reason for admission, specific intervention, length of stay and maternal outcome. A total of 43 women required admission to the intensive care unit (ICU), which represented 0.37% of all deliveries. The majority (95.3%) of patients were admitted to the ICU postpartum. The most common reasons for admissions were (pre)eclampsia (48.8%) and obstetric haemorrhage (37.2). The remainder included adult respiratory distress syndrome (6.9%), pulmonary embolism (2.3%) and neurological disorders (4.6%). Mechanical ventilation was required to support 18.6% of patients and transfusion of red blood cells was needed for 48.8% of patients. There were three maternal deaths (6.9%). A multidisciplinary team approach is essential to improve the management of hypertensive disorders and postpartum haemorrhage to achieve significant improvements in maternal outcome. A large, prospective study to know which women are at high risk of admission to the intensive care units and to prevent serious maternal morbidity and mortality is warranted.

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.

[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.

Infection in obstetric critical care

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

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 admissions to the intensive care unit: a 12-year review

OBJECTIVE

The objective was to ascertain the prevalence, causes and outcome of critically ill obstetric patients admitted to the intensive care unit (ICU).

DESIGN

The design was a retrospective collection of data.

SETTINGS

The setting was a multidisciplinary ICU in a University hospital.

PATIENTS

All obstetric patients admitted to the ICU over a 12-year period from May 1992 to April 2004 were reviewed.

METHODS

Data collected included demographic characteristics of the patients, pre-existing medical conditions, obstetric complications, invasive procedures required in the ICU and outcome of the patients.

RESULTS

The incidence of obstetric admissions to the ICU represented 0.22% of all deliveries during the study period. The majority (84.4%) of patients were admitted to the ICU postpartum. Obstetric haemorrhage (32.8%) and pregnancy-induced hypertension (17.2%) were the two main obstetrical reasons for admission. The remainder included medical disorders (37.5%) and other causes (6.2%). Associated major complications included adult respiratory distress syndrome (ARDS) and HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome. The perinatal mortality rate was 20% and the maternal mortality rate 9.4%.

CONCLUSIONS

A team approach consisting treatment by obstetricians, intensive care specialists and anaesthesiologists provided optimal care for the patients. Improved management strategies for obstetric haemorrhage and hypertension may significantly reduce maternal morbidity.

Obstetric admissions to an intensive therapy unit

Complications of pregnancy may necessitate admission to an Intensive Therapy Unit (ITU). All obstetric patients admitted to ITU were reviewed in order to assess whether these admissions could have been predicted and to determine the place of intensive care compared with high dependency nursing. Case notes of 122 women from a total group of 144 women admitted to an ITU of an inner-city hospital from 1989-1993 were reviewed retrospectively. The majority of women (67%) had no pre-existing medical or obstetric history. The major indications for admission were hypertensive disease of pregnancy (66%) and haemorrhage (19%); 79% followed caesarean section and 40% required ventilatory support. The perinatal mortality rate was 6% and there were three maternal deaths. The need for admission to ITU was unpredictable in two-thirds of the cases. Many of the women evaluated in this review were ineligible for high dependency care and required full ITU facilities, both of which will always be needed to deal with serious complications of pregnancy.

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.

Need for maternal critical care in obstetrics: a population-based analysis

The purpose of this study was to note potential obstetric risk factors leading to maternal intensive care and to estimate the frequency, costs and outcomes of management. In a cross-sectional study of intensive care admissions in Kuopio from March 1993 to October 2000, 22 consecutive obstetric patients admitted to a mixed medical-surgical intensive care unit were followed. We recorded demographics, admitting diagnoses, APACHE II score, clinical outcomes and treatment costs. The overall need for maternal intensive care was 0.9 per 1000 deliveries during the study period. The mean age (+/-SD) of the patients was 31.7 (+/-6.6) years and the APACHE II score 10.8 (+/-6.2). The most common admission diagnoses were obstetric haemorrhage (73%) and pre-eclampsia-related complications (32%). The duration of ICU stay was 5.8 days (range 1-31) and one of the 21 patients died in the intensive care unit (4.5%). The total cost of intensive care was in the order of USD 5000 per patient. Very few obstetric patients develop complications requiring intensive care. Although several risk factors associated with maternal intensive care were documented, most cases occurred in low-risk women, which implies that the risk is relevant to all pregnancies. Long-term morbidity was rare, and collectively the outcome of intensive care was good. Further research is needed to determine effective approaches in prevention, such as uterine artery embolization.

Anaesthesia and analgesia for the critically ill parturient

Anaesthetic and analgesic techniques in the critically ill are determined largely by the nature of the presenting illness. The commonest conditions likely to present as life-threatening emergencies are pre-eclampsia, obstetric haemorrhage, cardiac disease and severe sepsis. Issues dictating choice of anaesthetic technique are the patient's ability to maintain her airway, coagulation status, intravascular volume and haemodynamic dependence upon sympathetic drive, and requirements for ventilatory support and intensive care. Fetal well-being is an issue in the antepartum period, uteroplacental blood flow should be maintained and hypotension avoided. Maternal survival takes priority, however, and occasionally general anaesthetic techniques must be used which lead to neonatal respiratory depression and requirement for ventilatory support. Anaesthesia itself is associated with known hazards. The risks of each technique must be balanced against possible benefits in the context of the presenting illness.

Incidence and predictors of severe obstetric morbidity: case-control study

OBJECTIVE

To estimate the incidence and predictors of severe obstetric morbidity.

DESIGN

Development of definitions of severe obstetric morbidity by literature review. Case-control study from a defined delivery population with four randomly selected pregnant women as controls for every case.

SETTING

All 19 maternity units within the South East Thames region and six neighbouring hospitals caring for pregnant women from the region between 1 March 1997 and 28 February 1998.

PARTICIPANTS

48 865 women who delivered during the time frame.

RESULTS

There were 588 cases of severe obstetric morbidity giving an incidence of 12.0/1000 deliveries (95% confidence interval 11.2 to 13.2). During the study there were five maternal deaths attributed to conditions studied. Disease specific morbidities per 1000 deliveries were 6.7 (6.0 to 7.5) for severe haemorrhage, 3.9 (3.3 to 4.5) for severe pre-eclampsia, 0.2 (0.1 to 0.4) for eclampsia, 0.5 (0.3 to 0.8) for HELLP (Haemolysis, Elevated Liver enzymes, and Low Platelets) syndrome, 0.4 (0.2 to 0.6) for severe sepsis, and 0.2 (0.1 to 0.4) for uterine rupture. Age over 34 years, non-white ethnic group, past or current hypertension, previous postpartum haemorrhage, delivery by emergency caesarean section, antenatal admission to hospital, multiple pregnancy, social exclusion, and taking iron or anti-depressants at antenatal booking were all independently associated with morbidity after adjustment.

CONCLUSION

Severe obstetric morbidity and its relation to mortality may be more sensitive measures of pregnancy outcome than mortality alone. Most events are related to obstetric haemorrhage and severe pre-eclampsia. Caesarean section quadruples the risk of morbidity. Development and evaluation of ways of predicting and reducing risk are required with particular emphasis paid on the management of haemorrhage and pre-eclampsia.

Multicenter study of obstetric admissions to 14 intensive care units in southern England

OBJECTIVES

To identify pregnant and postpartum patients admitted to intensive care units (ICUs), the cause for their admission, and the proportion that might be appropriately managed in a high-dependency environment (HDU) by using an existing database. To estimate the goodness-of-fit for the Simplified Acute Physiology Score II, the Acute Physiology and Chronic Health Evaluation (APACHE) II, and the APACHE III scoring systems in the obstetrical population.

DESIGN

Retrospective analysis of demographic, diagnostic, treatment, and severity of illness data.

SETTING

Fourteen ICUs in Southern England.

PATIENTS

Pregnant or postpartum (<42 days) admissions between January 1, 1994, and December 31, 1996.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified 210 patients, constituting 1.84% (210 of 11,385) of all ICU admissions and 0.17% (210 of 122,850) of all deliveries. Most admissions followed postpartum complications (hypertensive disease of pregnancy [39.5%] and major hemorrhage [33.3%]). Seven women were transferred to specialist ICUs. There was considerable variation between ICUs with respect to the number and type of interventions required by patients. Some 35.7% of patients stayed in ICU for <2 days and received no specific ICU interventions; these patients might have been safely managed in an HDU. There were seven maternal deaths (3.3%); fetal mortality rate was 20%. The area under the receiver operator characteristic curve and the standardized mortality ratio were 0.92 (confidence interval [CI], 0.85-0.99) and 0.43 for the Simplified Acute Physiology Score II, 0.94 (CI, 0.86-1.0) and 0.24 for APACHE II, and 0.98 (CI, 0.96-1.0) and 0.43 for APACHE III, respectively.

CONCLUSIONS

Existing databases can both identify critically ill obstetrical patients and provide important information about them. Obstetrical ICU admissions often require minimal intervention and are associated with low mortality rates. Many might be more appropriately managed in an HDU. The commonly used severity of illness scoring systems are good discriminators of outcome from intensive care admission in this group but may overestimate mortality rates. Severity of illness scoring systems may require modification in obstetrical patients to adjust for the normal physiologic responses to pregnancy.

The role of a high-dependency unit in a regional obstetric hospital

The aim of our study was to review a series of critically ill patients admitted to a high-dependency unit (HDU) in a regional obstetric centre, to assess our HDU utilisation rate and to determine the indications for and rate of transfer to an intensive care unit (ICU) in a tertiary referral centre. A 4-year retrospective review of case notes and HDU/ICU registers was performed. One hundred and twenty-three patients were admitted to the HDU in the 2 years following its inception, representing 1.02% of all deliveries. Obstetric complications accounted for 81.3% of admissions. Seventeen patients were admitted to an ICU during the study period; 12 (0.08%) were transferred before and five (0.04%) after the development of HDU facilities (p = 0.25). The advantages of a HDU within this setting include the concurrent availability of expert obstetric care and critical care management, the avoidance of the hazards of emergency transport and improved continuity of antenatal and postnatal care.

National obstetric anaesthetic practice in the UK 1997/1998

In the United Kingdom, the Royal College of Obstetricians and Gynaecologists requires maternity units recognised for training to complete annual statistical returns. Analysis of these data revealed that anaesthetists were directly involved in more than 251 000 procedures in the peripartum period in 1997/1998. There had been an increase in the number of women delivered by Caesarean section (18. 5% of all deliveries) compared with previous reports. The proportion of Caesarean sections performed under regional anaesthesia had increased for both elective and emergency Caesarean section deliveries (85.5% and 70.2%, respectively). For pain relief in labour, there had been neither an increase nor a decrease in the uptake of regional analgesia (23.6%). There were limited training opportunities for anaesthetists in general anaesthesia for Caesarean section and for obstetricians in vaginal breech delivery. The known admissions to intensive care units equated to over 100 women per month in the United Kingdom requiring intensive care as a result of childbirth.